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. r AL A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. �-�ry Job Address . ( � S,, City Lot Size lao �(�S PM Owner's Name - 7`► - ' Address Phone Contractor— L� it 2 41L _Address r�Ot �� _ License No.61 J� � Phone + TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYS M REPAIR 1-1OTHER El DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ICULTUR WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private - ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout r I I Irrigation —_Approx. Depth 1 1 E ern urface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 \n TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other � //�� Number of living units: Number of bedrooms VA Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distante 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 Depth Size _ Number SUMPS `i,Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 subjebt 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." I - The applicant must call for I re inspe ti s. Complete drawing on reverse side. ' Signed X Title: 42.d4,4 A, Date: FOR DEPARTMENT USE ONLY f 3 Application Accepted by Date `,� Area Pit or Grout Inspecti y Date Final Inspection byf/f""' -� DateaSY Additional Comments: ❑ Stk 466-6781_ ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE_ INFO AMOUNTQDUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. µ ♦ EH 13-24tREV.t/H51 * f �� EH 14-28 1 C7