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�Jy APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (249) 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. i Job Address ti:� /7'"�/kI (S/� _. City I7� Lot Size PM Owner's Name a. � 1 Address :+ Itf< j � Phone Contract Address t 1�� C3�( ?� C%�"rrr License No.c ' Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ FPUMP INSTALLATION C1SYSTEM REPAIR ❑ OTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS RINTENDED 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 Fik, LJPublic LIOther LJDelta Depth of Grout Seal Type of Grout ❑ Irri ation _A g ---Approx. Depth Cl❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ r I Well Destruction ❑ Well Diameter Sealing Material (top 501 W Depth '11 r Material (Belo ') 6 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence .Commercial Other i Mumber of living units: Number of droo 3� f ' 'Character of soil to a depth of 3 feet: Water table depth G, F11 SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r j LEACHING LINE ❑ No. & Length of lines`. Total length/size t� FILTER BED ❑ Distance to nearest: Well Foundation Property Line Oa SEEPAGE PITS Ell' Size Number SUMPS ❑ Distance to nearest: Well / 2 Foundation 10 Property Line I 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 9 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 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." Theapplicant ust call far all req 'ed inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY FApplication Accepted by Date Area Pit r Grout Inspection by Data Final Inspection by Date i I Additional Comments: ❑ Stk 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 F! FEE ppp - INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERMIT'NO. �F+ EH 13-24(REV.it.e sl 1lkkkk..ii!! EH 14-29