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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' r , 1601 E. HAZELTON ON AVE., STOCKTON, CA II 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 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 Disttriccttf. op � 1� 11 �a}h��f.�x Job Address �'—� J `�+ o �" 3c x �� ) �-,�(1(I �7�J cCity [rLnat�Size WPM Owner's Name '_yo ' tOar '� Address.�"y�� s �. ��6�� Phone u Contractor PJA Address License No. _ Phone $� TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ A i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:,SEPTIC TANK ? SEWER LINES DISPOSAL FLD. PROP. LINE k FOUNDATION- AGRICULTURE WELL-`tk '�"' OTHER WELL- °iPITS/SUMPS INTENDED USE ° . " TYPE OF WELL PROBLEM AREA`,-CONSTRUCTION SPECIFICATIONS' ❑ Industrial �❑ Open Bottom Q Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy d { 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 Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth - Filler Material IBelow 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �ax; r j1�� 'available within 200 fee ► Installation will serve: Residence Commercial Other �] ��/Q� r� . �f�•� ,: Number of living units:� Number of edrooms f'� r Character of soil to a depth of 3 feet:-.- Water table depth 0 /} SEPTIC TANK Type/Mfg Capacity -No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well + P� Foundation 0, % Property Line • �4 w. LEACHING LINE No. & Length of lines _ I length/size FILTER BED ❑it Distance to nearest: Well—Mb/ Foundation Property Line,"+<A/ f Iy SEEPAGE PITS )<-,,Depth Size 1"rl ' Number SUMPS ❑ Distance to nearest: Well� Foundation s Property Linez t DISPOSAL PONDS ❑ 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 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." The applicant must tali for all required inspections. Complete drawing on reverse side. .. � Signed X A�. Title: Date: ---- 1 A. FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspec ion by ate i W_ t � w SAdditional Comments: hE '❑Stk'466-6761 ❑ Lodi 369-3621 171 Manteca 823-71 ❑ Tracy 835-6385 ° Applicant- Return all copies to: Environmental Health Permit/Services;1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA*- RECEIVED BY DATE PERMIT'NO. 1 + EH 13-N(REV.1i H 57 EH 1428 :