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APPLICATION FOR PERMIT ■ SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E..HAZELTON AVE., STOCKTON, CA Telephone (200) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' .- (Complete hi Triplicate) 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. ? ' r «J /" Ci r Job Address � City Lot Size PM Owner's Nam \`v r V'� 1 i /� �' Address v r I C j Phone `r r r � Contractor. �, �r _ 'Address License No. Phone 41 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ IS RES C TANK SEWER LINES DISPOSAL FLD. PROP. LINE li AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ---CONSTRUCTION SPECIFICATIONS L] Industrial Ll Open Bottom ElManteca�� Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casl Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout,Seal -Type of Grout A ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by' Repair Work Done ❑ Type of Pump H.P. State Work Dohe Well Destruction ❑ Well Diameter - Sealing Material (top 501 II Depth Filler Material (Below 501 E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIOo eptic system permitted if public sewer is ble within 200 feet.} Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: ? ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation f- Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well i' Foundation Property Line SEEPAGE PITS ❑ Depth -Size ° Number SUMPS ❑ 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. i ! Home owner or licensed agent's signature certifies this fallowing: '=1 certify that in the performance of the work for which this permit is issued, 1 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 t call all re u d in�� Completerawing an reverRse sideSigned - . Title: ( NL 1�J4 Date: ^� ` FO - EPARTMENT USE ONLY i Application Accepted by Date / v Area G Pit or Grout Inspection by DateFinal In 'on by Date Additional Comments: I ❑ Stk 466-6761 L1 Lodi 369-3621 ❑ Manteca 823-7104 13 Tracy 8354OZ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 C FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. Y INFO �j CASH + EH 13.241REV.t/a57 EH 14-28 �J