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APPLICATION FOR PERMIT HEAL� SAN JOAQUiN LOCAL HEALTH DISTRICT i tv� 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES I 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. I Job Address City.oLot Ske PM Ar 7j Owner's Name'> V Address •Phone Contractor's Neme License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑' I 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 Die. of Well Excavation Die,of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Deka Depth of Grout Seal Type of Grout ❑ Irrigation —.Approx. Depth ❑ Eastern Surface Seal Installed by t O 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material(top IW) Depth Filler Material(Below 56') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION g (No septic '1 system permitted if public sewer is available within 206 fast.) 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 PKG. 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 j SEEPAGE PITS O Depth Size Number f SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is Issued, I shell not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub- ntracting 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 m call fora required inspections. Complete drawing on reverse side, t mae _ Si gnd fie' -�l ._..__.. Data: � a j FOR DEPARTMENT USE ONLY Application Accepted by Date W Z S �U Area 6 r Pit or Grout Inspection bDate Final Inspection by Date_4t71_ � i r Additional Comrrle'hts: LI Stk 466-87131 13 Lodi 3&33021 ❑ Manteca 023-7104 Tracy 835.63136 an r f! Applicant-Return all copies to: Environmental Health PeServices 1601 E. Hazelton Ave., P.Q. Box 2009, Stk.,CA 95201FEE ' INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY CASH DATE PERMiT`NO. i 13-24 TREY.101831 EMN W26