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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. /' '/ ^''� , - 99 A-5- • rfL City i• ! - Lot Size PM Job Address ^^ //�� Owner's Nam..rn o hn.c..w— Address Phone r. r1�� / r � ss —.X Contract.7- Addressf' &�V�e- e License No. J Phone'3�'� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT�❑ DESTRUCTION ❑1+p ` PUMP INSTALLATION ❑ SYSTEM REPAIR r- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L�(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other n Delta Depth of Grout Seal Type of Grout r I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done V, Type of Pump.;Va6d�_ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) 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 ofjD� pgslR Distance to nearest: Well Foundation Property Li C� `�a71' 1� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i Z 0 M9 SEEPAGE PITS 1 I Depth Size Number ckly(OONME lD E LTH SUMPS ❑ Distance to nearest: Well Foundation Property Line[>F MVICFc 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 r rules and regulations of the San Joaquin Local Health Di3trict. 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." ` The applicant must cal for all required i,spections. Complete drawing on r verse side. Zz Signed Title: a� Date: ��✓ / _ //JJ,�yy ; OR DEPARTMENT USE ONLY Application Accepted by _/5 %i%OSi Date / Area 2 Pit or Grout Inspection by Date Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH (� EH1124(REV.rix sl 3`s � EN 142!