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I Ft APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTviiCT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 R..+ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 } Job Address �'/� (/l�• City Lot Size PM Owner's Nam L Address [ `vim /To4 tJG j Phone s .2 Contractor � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ T DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL 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 ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications P Public i 1 Other 171Delta - Depth of Grout Seal Type of Grout I I Irrigation '—.Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 501 41 Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION (I FIEPAIR/ADDITION I I DESTRUCTIONINo septic system permitted if public sewer is " -.- available within 200 feet.) Installation will serve.- Residence— Commercial— Ocher Number of living units: Nurribef of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property-Line LEACHING LINE ❑ No. & Length of lines - Total length/size 'i FILTER BED ❑ Distance to nearest: Well Foundation Property.Line SEEPAGE PITS C I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 j rules and regulations of the San Joaquin Local Health Di§trict. 1 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 F 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." f The applicant st r requir inspecti `s. omplete drawing on reverse side. Signed X Title: — Date: FOR DEPARTMENT USE ONLY Application Accepted by ..-._._ _- date Area Pit or Grout Inspection by Rate Final Inspa tion by Date *1 _ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REWTEp CK INFO SFt RECEIVED BY ,DATE PERNlIT'NO. 191 4 C+.EH 13-24 fREV.iiwsl --jt EH 14-2e G