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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 vkh San Joaquin County Ordinance Np.' 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City 1'/�/rc,t1 Lot Size �c PM r Owner's Name Address ! 4i��4� 4 Phone Contractor's Name 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 --Approx. Depth ❑ Eastern Surface Seal Installed by T f P H P State Work Done Repair Work Done ❑ ype o ump Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADQJ�I DESTR N ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _A!L5- Commercial _ Other k r"" Number of living units: _j.— Number of bedrooms Character of soil to a depth of 3 feet: S'r�iv� r�A-I►�Z Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments - PKG..TREATMENT PLT. ❑ Method of Disposal . Distance to nearest: Well Foundatioh Property Line • I i . LEACHING LINE ❑ No. & Length of lines ER BED Distance to nearest: Well PITS ❑ Depth Size y Total length/size_ 7-Fg+ndation_ Property Line Number SUMPS ❑ 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 San7Joaquin county ordinance's, 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 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." �1. The applicant must call f' II re d inspections. Complete drawing on reverse side. Signed Ir Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byi Date ZDY Area Gj Z o Pit or Grout Inspection by Date Final inspection by Date ! • t -Additional Comments:-. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104.ElTracy ,835-6385 ,..,.".APplicant - Return all -copies -to: Environmental Health PIermit/Services 1601 E. Hazelton Ave., P.O. Box 2009,. Stk., CA 95201 Ma FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO