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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 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 _ l�I T � City "� Lot Size Y PM_ Li Owner's Name Address 3 rad Phone Contractor's Name License No. _ Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1$ I '"` OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE I. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAr CONSTRUCTION SPECIFICATIONS ❑ Industrial N ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ! Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy r Type ff Casing Specificatiops Public 1-1Other L (71Delta f" Depthh of Grout Seal Type of Grout ❑ Irrigation _--Approx. Depth ❑ Eastern SurfceSeal Installed by Repair Work Done JR Type of Pump H.P.b ' State Work Done Well Destruction ❑ Well Diameter Sealing Materia(top Depth `� Filler'Material (8el'ow 501 , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet. Installation will serve: Residence_ Commercial_ Other Number of living Iunits: Number of bedrooms *%r —4 f I , f Character of=foil to a depth of 3 feet: Water table depth SEPTIC TANK .s ❑ Type/Mfg Capacity No. CompartmentsE PKG. TREATMENT PLT. ❑ s 'Method of Disposal �* Distance to nearest: Well''- F.o(indation Property Line o 14 LEACHING LINE ElNo. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: WellFoundation I Property Line 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 Joaquin Local Health District. 1 1. 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: "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 EIS 0 a req red i s ctions. Complete drawing on reverse e. Signed ! Title: ��i �3 Date: _ -� 1 may" , FOR DE ARTMENT USE ONLY !/1/ x a Z Application Accepted by Date Area - • 1Z Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: }a i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8358385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 F i f FEE AMOUNT DUE AMOUNT REMITTED CK 'RECEIVED BY DATE'. PERMIT'NO. INFO CASH // ��(/ +EH 13-24 MEV.10/931 Ld V //, U EH 14-28