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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT tl& UALL Imo^^►° 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 3 ; PERMIT EXPIRES'i 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."... ... F 7 { Job Address l� ! fS Ci r Lot Size 7 ,5_X 7X�. 0 PM + jOwner's Na �"D�+1/ t,�Address ��,� �/ Phone t 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 FLD. PROP. LINE FOUNDATION 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 ❑ Domestic/Private , ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ____4prox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth Filler Material.(Below_50')- --- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION_ (No septic system permitted if public sewer is -- --r«- - t vailable within 200 feet.) r}. p, Installation will server Residence— Commercial _ Other Number of living units: Number of bedrooms [ Character of soil to a depth of 3 feet:� w a Water table depth fi SEPTIC TANK ❑ I Type/Mfg Capacity r No. Compartments PKG. TREATMENT PLT- ❑ _._ Method of Disposal Distance to nearest: Well Foundation - Prop-erty'Line�" LEACHING LINE ❑ No. & Length of lines r 4 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property-Line SEEPAGE PITS ❑' Depth Size Number SUMPS. _ ❑ Distance to neatest:` Wel Foundation ' Property Line DISPOSAL PONDS El 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 f 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 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.". 1 _ The applicant must call for all required inspections. Complete drawing on reverse side. I Signed XL 'lI6�.fes Cy g � �-;.rs� Title: Date: F R DEPARTMENT USE ONLY Application Acceptedby �„/� Cw` i� Date T-y I Area J y ` Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 .❑ Lodi 369-3621 ❑ Manteca 823-7104 .❑-Tracy 835-6385 ( Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE Kf INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r + EH 14-28(REV.1/851 :. l✓