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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA !i Telephone (209) 466-6781 PERMIT EXPIRES�'I YEAR FROM DATEISSUED _ t # (Complete in Triplicate) f. 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. Job Address - i City L} Lot Size PM Owner's Name Address -32- 6F !! � U p u Phone Contractor/` � { Address - / X/ &&-�. License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I 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 W i ❑ 'Public ❑ Other 111 Delta Depth of Grout Seal Type of Grout dd 4❑ Irrigation ____�pprox, Depth,,. ❑ Eastern Surface Seal Installed by eik) t Repair Work Done ❑ Type,`of Pump H.P. State Work Done, { Well Destruction - ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ;. available within 200 feet.) 5�11 S: Installation will serve: Residence_ 'Commercial, Other Number of living units: j' Number of'bedrooms Character of soil to a depth of 3 feet: A4 4� Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ !)`' Method of Disposal Distance to nearest: Well Foundation Property Line ; t 0 01 LEACHING LINE W N0. & Length of lines Total length/size v- FILTER BED ❑ Distance to nearest: Well_d_ Foundation 'Property Line _ a SEEPAGE PITS ❑ De"th 2 +s Size12, umber d ' ., SUMPS ❑ Distance to nearest: , Well/d � Foundation� Property Line DISPOSAL PONDS ❑ iN f 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 rules and regulations of the San'Joaquin Local Health District. W 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 i 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 applscia7 must call for II requirgA inspections. Complete drawing on reverse side. s Signed X Title:. _.- Date: _ FPR DEPARTMENT USE ONLY lication Accepted bV C Date 'I Area 0 ((�� t ' V�it r Grout Inspection by l� .�,.� ^__Date O Final Inspection by Date i!O II - Additional Comments: !i ❑ Stk 466-6781 ❑ Lodi 1369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.:Box 2009, Stk., CA 95201 FEE r }NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INI y + EH 13-24IREV.tin51 41 t EH 14-28 �d I� I }