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I APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 4 YEAR FROM DATE ISSUED (Complete in Triplicate) (;.` WO��t4 Application is he+eby 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. Q Job AddressrZS,LL o City Lot Size PM Owner's Name L - Address1 Phone weo_A&n .gas 43 pp Contractor Address se No. 7��' Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ f —DISTANCE TO NEAREST: SEPTIGTANK - --- SEWER-LINES; DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL R OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing iplomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i I irrigation —.Approx. Depth ( 1 Eastern Surface Seal Installed by _ Repair Work Done X—Type of Pum . , H.P. rState Wok Done Q Well Destruction ❑ Well Diameter Sealing Material stop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION l I (No 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 �iPKG. 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 1 Depth Size Number SUMPS Ll .Distan-ce to nearest: Well Foundation Property Line .�.,.;r �: ��-__°- : :. -tea...::':,.�^--�---�. •- DiSPOSAL PONDS ❑ �••` - I hereby certify that I have prepared this application and that the work will be done-in accordance with Sart Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dikvict. 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, 1 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 ca a requiredrr�spe tions. Complete drawing on r verse side. _ �s Signed X Title: Date: �� FOR R MENT USE ONLY /U� Application Accepted by Date v/ Area i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 EI 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO.. r ♦ EH13-21(REV.ti Hat « t Jt 79 1 3S EH 4-28 VV