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-* APPLICATION FOR PERMIT �� SAN JOAQUIN LOCAL HEALTH DISTRICT NO € 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;,..(Complete in Triplicate) F Y p 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. L Citi' Lot Size PM Job Address �, ,, � (NCL i� Phone 4(4 Owner's Name)&,00 tv 4 Address W Contractor Address License No. {! Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP...LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ,. Dia.,of Well Casing E1 Domestic/Private [I Gravel Pack Cl Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _�Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ l Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 171DESTRUCTION INailabo eptiws in m emitted if public sewer is Installation will serve: Residence— Commercial— Other I � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 7 I _ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 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. 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 I employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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." Pf A I The applicant rr, all fo I. rn�R ^tions. Complete drawing or rse side. -- bRCI Signed X_ wa^ Title: Date: 3 K®f( / i � �I�u � DEPARTMENT USE ONLY I . Date 3 13"S7 Area r Application Accepted by Pit or Grout Inspection by Date Final Inspection by Date �✓� Additional Comments: C] Stk 466-6781 LJ Lodi 369-3621 ❑ Manteca 823 7104 L1 Tracy 635 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box•2009, Stk., CA 95201 i FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT ND. INFO +,EH 13-24(REV.11851 EH 14-28