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w f APPLICATION FOR PERMIT t4l' SAN JOAQUIN LOCAL HEALTH DISTRICT C + 1601.E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED .,.c• .v (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. p Job Address 1�o/ T,�a �� Sf Lot SizeJ��/1 PM Owner's Name / _ Address �C�d ��r/a�d Phone '7'— Contractor B I Address /� �/V/Q/{l License No. �� Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Q l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWE INES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICUL RE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA N UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type f Casing Specifications ❑ Public ❑ Other ❑ De Depth f Grout Seal Type of Grout LlIrrigation --Approx. Depth Eastern Surface eal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done' Well Destruction ❑ Well Diameter _ Sealing Material (top SO') "'-- --' Depth ;_Filler.Material-(Below 50') TYPE OF SEPTIC WORK: NEW IN ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence=: Commercial_ Other Number of living units: �<Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK T ype/Mfg a _ Capacity No. Compartments ZL PKG. TREATMENT PLT. El dvvz: Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑. .Distance to nearest: Well Foundation Property Line � I SEEPAGE PITS ❑ Depth Size Number .SUMPS ❑ Distance to"nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Joaquinl 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; "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." r The applicant must call or all re 'red ins ions. Complete drawing on reverse side. Igned Titfe: T Y Date: l �% FOR DEPARTMENT USE ONLY Application Accepted by Date — ' Area �� Pit or Grout Inspectio Date Final Inspection Date3�d 17 Additional Comments: .ten ❑ Stk 466-6781 ❑ Lodi 13W3621 ❑ Mante 7104 ❑ Tracy .83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1$01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE t AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �IREV.t/M 4 J e9 L � ) E I 3—/3--F-7 _