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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION 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. 11 Y (' Job Address cJ��" r 11. Y City Lot Size �Ly PM ~ Owner's Name Address �GV"1 Phone - }i ! r Contractor's Name `bLt c2 License No. '" Phone G a� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ f DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR [7 - ' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKO SEWER LINES r}CJS DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL } PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing } Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ;Type of Grout ❑ Irrigation --Approx. Depth El Eastern Surfa a Seal Installed by 4 Repair Work Done ❑ Type of Pumps H.P. State Work Done e Well Destruction ❑ Well Diameter, �/ Sealing Material (top 50'1 f Depth __., Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.I E � . 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. Q e: ; f' o ,�; Method of Disposal Distance to nearest:""'^"Well 4—"foundation-" " "'^ " "Property L ne LEACHING°LINE ❑ No. & Length of lines' ?' `� w Total length/size 1 FILTER BED 1W ❑ Distance to nearest: Well Foundation Property Line . ��_._ Number SEEPAGE PITS. i ❑ Depth Size 1 f_. SUMPS ! a ❑ ,Distance to nearest: Well Foundation Property Line _ . DISPOSAL PONDS-_ 'El 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 far 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 persons subject to workman's compensa- tion laws of California." } The applica must c for all rredopsyNtions. Complete drawing on r verse side. y .Signed ' Tit1e:� !1.� °"l-�' _. Date: (0 -FOR.DEPARTMENT V46ONLY - ...-� ' w••.w�_ ..1.�+�-J�L.�. Application Accepted by Date Area i 7-3l � Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: - ❑ Stk 466-6781 Cl Lodi 369-3611 L7 Manteca 823-7104 ❑ Tracy 835.6385 i € a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,'CA 95201 FEE" AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH f� + EH 13-21 IREV.101831 O �1 EH 1428 . r