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i «-� APPLICATION FOR PERMITIN 0 _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 .�; PERMIT EXPIRES 1 YEAR FROM DATEISSUED : .. ; I (Complete in Triplicate) �g 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. Ile - ' �X j M Job Address 1 City Lot Size �I r Owner's Nama Phone Contractor ressL -cense Nc�/ Phone TYPE OF WELL/PU NEW WELL i❑ WELL REPLACEMENT ❑ I DESTRUCTION ❑ t PUMP INSTALLATION '❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST-.SEPTIC TANK 3 SEWER LINES DISPOSAL FLD. P . LINE FOUNDATION _,. AGRICULTURE WELL OTHER WELE'• j PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC S ❑ Industrial ❑.Open Bottom p Manteca Dia. of Well Excav Dia. of Well Casing ❑ Domestic/Private 'Gravel Pack- # ❑ Tracy Type of ng Specifications ❑ Public ❑ Other Delta epth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ n Surface Seal Installed by' Repair Work Done ❑ Type of P H,P. - - -- State Work Done Well Destruction ❑ iameter Sealing Material (top 501 Depth Filler Material (Below 501 , TYPE EPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is r 1 f 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 r ' SEPTIC TANK ❑ T e/Mf ;w i YP 9 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f t Distance to nearest: Well t Foundation Property Line LEACHING LINE ❑ No. & Length of lines 1 Total length/size FILTER BED ❑ Distance to nearest: i Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number _q 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. 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 4 „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 m st f 11 qui .d inspections. Com to drawingo 77 rse side. ti Signed Title: Date: FORD ARTMENT USE ONLY y Application Accepted by r "f Date Brea f Pit or Grout Inspection by D e Final in cti n by pat Additional Comments: R .❑ Stk 466-6781 ❑ Lodi 3693621 ❑ Manteca 823-7104 ❑ Tracy/835-6385 `, '.Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 -,�\�y1�•�`,VI''� AJ I = `y ,1`�✓ i FEE AMOUNT DUE AMOUNT REMITTED CK# INFO CASH RECEIVED BY PATE PERMIT N0. + EH 13-24(REV,1/at) ` //,�_ �J� EH 1,428 3