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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES '(-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. _ �j-y� I (Y(, Zz0 e ' ray r_ - } � f Job Address ��i-t .1 �h[31V1 S �/�+� x City ,r Lot Size PM Owner's Name 1C F��iC!L e-1 1_G ,._ Address �{ C� 1 �l J T Phone 3,0G-T7 Co ractor J tc Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUM STALLATION ❑ SYSTEM REPAIR ❑ -- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR LE EA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom D ante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (l Public f Other Cl Delta epth of Grout Seal Type of Grout _. V I I Irrigation rox. Depth l I Eastern Su Seal Installed by _ rn Repair Work Done EJTy a of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION INo 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 SEEPAGE PITS i I Depth Size Number SUMPS L1 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."Contractor's 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 parsons subject to workman's compensa- tion laws of California." The applicaFAaukst call for all required inspections. Complete drawing on reverse side. igned X Un 110 Title: .0w ra C-fz- Date: ` 4NJ V FOR DEPARTMENT USE ONLY Application Accepted by _ Date "4 ZG rea Pit or Grout Inspection by Date F' al Inspection by 7 + �/ Additional Comments: ] 1 1`n-7 '� ,,�� Im ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 835-6385 Applicant- Return all copies to Environme al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk�CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER3;;,; . + EH 14-261REV.tiK5) � s- =�� ,13 - y g�