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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT1-f"tL! 1601 E. HAZELTON AVE., STOCKTON, CA T Telephone (209) 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 dexribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/Dump and the Rules and Regulations of the San Joaquin Local Health District. �y ` 1 1 C�-,.�, Job Address 2 O s� N�W� 'L-� �� city t�!r�T�iK,—rrn♦-.Ckot Size PM Owner's Name �y A4 Re)T Address ,Y51 ^/ E _) tD_� Phone Contractor I-C Address License No. - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing Specifications Il Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ \JJ Repair Work Done ❑ Type of Pump H.P. State Work Dane_ OQ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will e: Residence_ Commercial_ Other Number of living units. Number of bedrooms Character of soil to a depth feet: r table depth SEPTIC TANK ❑ Type/ Ca No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal ` \ Distance to nearest: FoundationProperty Line l\ LEACHING LINE ❑ ength of lines Total length/size FILTER BED Distance to nearest: Well Foundatl Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property line DISPOSAL PONDS ❑ I hereby certify that 1 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 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."Contractors 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 call for all required instpeecctio-ns. Complete drawing on reverse side. Signed X �A DM cl�C..(/4�o, Tit1a: Date: FOR DEPARTMENT USE ONLY Application Accepted by �' Date"ate Area 0 Pit or Grout Inspecti Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8345-6385 � Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. HazeRon Ave., P.O. Box 2009, Stk.,CA 95201 -`1,\�\`\ FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. \ INFO \ e . EH13241REV.vxm 1 �Z EH 14.25