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w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,;STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED . u (Complete in Triplicate) ;x.•� 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 D' tr t:- Job Addres� _ _ City 6_tC� Lot Size PM 1 Owner's Name 9- Address _ � -�-.� „_, Phone F Contractor Address F02f �r9 �rc.� _License No. SF3�� Phone TYPE OF WELL/PUMP: I NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK T SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION V1� 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 1 Kpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Y Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed bye` . / y Repair Work Done LJ Type --':'Type of Pump H.P. State�Work DoneLq � �r Well Destruction ❑ WellDiameterSealing M terial (top 50') / t Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION F1DI REPAIR/ADTION ElDESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other �� 3 Number f�lunits: Number of bedrooms j Character of soil to a depth o Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No___Compariments PKG. TREATMENT PLT. ❑ 't ,Method of Disposal Distance to nearest: Well I Foundation Property LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: WellFoundation Property Line i SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: Well Foundation Property'Line DISPOSAL PONDS ❑ I hereby certify that l 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 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: "1 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." s The applicant must call for all required inspections. Complete drawing on reverse side. l Signed Title: _ bate: FO EPARTIVI NT USE ONLY Application Accepted by _ Date �/ f Area a�Pit or Grout Inspection by DateFinal Inspection rDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante_ca 623-7104 ElTracy 835-6365 F Applicant- Return all copies to: Environmental Health Permit/5ervices 1601-E."Hazelton Ave., P.O.-Box 2009,.Stk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH1324 411 EH J EH 1424