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: - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL:HEALTH DISTRICT l �� 1601 E. HAZELTON AVE.,:STOCKTON, CA —"Telephone (209) 466-6781 . , l ,.. ` n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. :{ +( (Complete in,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. �'City Lot Size PM' ob Address Owner's Name dress r �`' a 1 Phone 116' - Contractor I Address License No. Phone TYPE OF WELL/PUMP: �. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ElPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r `' FOUNDATION —% t' OUNDATION * AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type 1-1Domestic/PrivateTestic/Private ❑ Gravel Pack ❑ Tracy YP of Casing Specifications LJPublic ❑ Other ❑ Delta Depth of Grout Seal . Type of Grout ❑ Irrigation ___! pprox. Depth ❑ Eastern Surface Seal Installed by __—A Repair Work Done ❑ Type,�of Pump H.P. State Work'Done Well Destruction ❑ Well Diameter Sealing Materia! (top 50') Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence_ Commercial Other g Number of living units: �I' 'Number of bedrooms Character of soil to a depth of 3 feet: Water table depth - SEPTIC TANK X Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. EJl!� & Method of Disposal Distance to nearest: Well Foundation Property Line .I� LEACHING LINE ❑ No. & Length..of lines K Total length/size FILTER BED ❑ Distance to nearest: Well Foundation, Property Line F' SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well t foundation ``Property Line . ,c. 'i DISPOSAL PONDS ❑ 11 i 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. F 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.",t. I The applicant must call for all (required inspect i ns. Complete drawing on reverse side. Date: Signed X Title:: - DEPARTMENT USE ONLY ~�� - Application Accepted by Date Area 7 by Dat6_ l Insp cti E i Date Fina Pit of Grout Inspection �9 t. �0 Additional Comment ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. Box 2009, Stk., CA 01 Dluy,v,14) FEE AMOUNT DUE AMOUNT REMITTED7 CK RECEIVED BY DATE PERMIT'NO. INFO +EH 13-24(REV.1ie51 EH W28 _ ,.