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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �l 1601 E. HAZETON AVE:., STOCKTON, CA Telephone {2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Tiriplicatel Application is hereby made to the San Joaquin Local Health District for a permit i#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 e r C�� 0 I[ r City Lot Size�0 0 PM Owner's Name - - E .S !7 Address �Z� C$ PhomaQ Contractorf�K� e0 91 Address License No.3We.l Phone ��! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM_ REPAIR ❑ OTHER L1DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM REA CO RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation pia. of Well Casing ❑ Domestic/Private © Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ D Depth of4Grout Seal Type of Grout ❑ Irrigation --Approx. Depth Eastern urface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Mat Ea! (tap 50') Depth Filler Material elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION_ El "DESTRUCTION (No septic system permitted if public sewer is � available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I) Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well oundation Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well Vation Property Line SEEPAGE PITS ❑ Depth f SizeNumber SUMPS © Distance to nearest: Well Property Line DISPOSAL PONDS ❑ I hereby certify that l have prepared this application and that the work will be done Nn 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. tion laws of California." permit is issued, I shaft employ persons subject to workman's compensa The applicant mu call for all required inspections. Complete drawing on reverse side. V Signed ' Title: (� Date: 9 I� FOR DEPARTMENT kk USE ONLY �Application Accepted by2)1 Date 9 Area p� Pit or Grout Inspection by Date Final Inspection b Date��i Additional Comments: 41 ❑ Stk 466-6781 D Lodi' 369-3621 ❑ Manteca M7104 El:Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 q elzN FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13.241REV.1/851 3 �• V� ��f1 `� -��^� 1 �(�r y� EH 14.28 U I