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i . f APPLICATION FOR PERMIT SAN JOAQUI!N LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA NO W Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED �\ (Complete in Triplicate) r � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name Address �� ' —•_ Phone Contract x Address._��34 4. c�,�License0 Phon 0 TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL LIMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP ONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack © Tracy ype of Casing Specifications C] Public Cl Other Cl Depth of Grout Seal Type of Grout — I I Irrigation _._Appro i I Eastern Surface Seal Installed by _ Repair Work Done ❑. of Pump H.P. State Work Done _ Well Destr Q Well Diameter Sealing Material (top 50') — Depth Filler Material lBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION i I DESTRUCTIO INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_.. Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ��llll SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for all required inspections. Complete drawing on re se side ^ Signed X pool Title: .._ Date: / F R 1p PARTMENT USE ONLY Application Accepted by �� .4._ 0��_ Date 21-674 I Area10 F-7 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ 1 ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 lFEEO AMOUNT DUE yAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r.EH 13-24IREV.t/w51 �y�^ tta EH 11-28