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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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. C — Job Address ' City Lot Size iiPM � Owner's Name dress Phone 4yf Contractor ddress License No./ Phone TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public F1 Other R Delta Depth of Grout Seal Type of Grout - i I Irrigation. —.Approx. Depth 1 1 Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of Pu rnp H.P. State Work Done r. " Nell Destruction ❑ Well Diameter_ Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIDDITION l I DESTRUCTION { I (No septic system permitted if public sewer is per/ available within 200 feet.) Installation will serve: 'Residence Commercial Other ff Number of living units: 4— Number of bedrooms Character.of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We1l—ad—' Foundation�� Property Line LEACHING LINE ❑ No. & Length of lines 4— � Total length/size oV � FILTER BED ❑ Distance to nearest: WeIIrI Foundation 112 Property Line 1Z �SSEEPAGE PITS l I Depth Size M1lumber 1 UMP5 LlDistance to nearest: Wel! oundation �[ Property Line DISPOSAL PONDS ❑ I hereby certify that I have 4epared 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. Q' 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 signatu4\� 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- lion laws of California." ' _ The applican f r I e6q9ir9d ins 4,;ff n . Corig o e se side. Signedfate: PARTMENT USE ONLY ~ Application Accepted by t'� Date f 7a— Pit or Grout Inspection by Date Final Inspection by4. V Data ` �o c7 U 2 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f IFEE AMOUNT DUE AMOUNT REMITTED CK i GASH RECEIVED BY DA/T/E� PERMIT'NO. . ,! F!+,EH 4(REV.tixai 47c) E1t1/-2