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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CA �1 ; Telephone (209) 466-6781 ! PERMIT EXPIRES 1YEAR FROM DATE ISS 1 "�U,1,•� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District foraermit to construct and/or install the work herpin-dbscnbft•.This application is p _ ti-• rvV,_ made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and'R 1 egolations of the San Joaquin Local Health District. {'� 2 Job Address 6/9 Ja° City Lot Size PM C_ Owner's Nam Address Phone �f ^��. Contract ' ._- Address�� r� � _ � Q � �Icense No. Phone L3 C--I 1 TYPE OF WELL/PUMP: NEW WELL ❑` WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION fd SYSTEM REPAIR CJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION - AGRICULTURE WELL OTHER WELL: -- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'KIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r 'Domestic/Private ❑ Gravel Pack ❑ Tracyt Type of Casing Specifications M Public Ll Other F1 Delta -4 ..w_ Depth of Grout Seal Type of Grout I I irrigation _,Approx. Depth I I Eastern Surface Seal Installed by " Repair Wotk Done X Type of Purnn.rim H.P. r State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 r- r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted it public sewer is 4 n ; 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 t Total length/size Y FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line ' DISPOSAL'PONDS ❑ r € 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 Df%trict. 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 persons subject to workman's compensa- tion laws of California." The applicant must c 'for allquired inspections. Complete-drawing on reverse side. Sign Title: a i Date: �—7 FOR DEPARTMENT USE ONLY Application Accepted byDate Area Pit or Grout Inspection by Date 'Final Inspection by Date C�87 �` Additional Comments:_ ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED"" CK RECEIVED BY DATE PERMIYNO, INFO CASH +.EH 13-24 1 REV.1/8 57 C-, EH 14-28