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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT \�\T� 1601 E. HAZELTON AVE., STOCKTON, CA 1 ✓� ^ ,Q� Telephone (209) 466-6781 1 / a t" V PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) _�ZZJ\GAS )ice�•`'his Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described\1This 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. Fr spa A C Job Address '' City Lot Size PM Owner's Name Address a Phone Contractor C Address A7,10am'49 License NoS? c Phone TYPE OF WELL/PUMP: NEW WELL-D' WELL REPLACEMENT ❑ 'DESTRUCTION ❑ PUMP INSTALLATION ❑ ' ; SYSTEM REPAIR' I 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 pi�pomestic/Private ❑Gravel Pack ❑Tracy Type of Casing Specifications D� 1`1 Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth J I Eastern S ace Seal Installed by _ Repair Work Done 59 Type of Pump H.P. I! State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material(Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION I I DESTRUCTION l 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 of Disposal Distance tti,nearest: Well " Foundation Property,Lirie ! I LEACHING LINE ❑ No. & Length of lines Total length/size , FILTER BED 11Distance to nearest: r Well { Foundation Piopeity Line SEEPAGE PITS ( I Depth {'� Size Number 1 A SUMPS ❑ Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS ❑ ( .�• �. I hereby certify that I have prepared this applicatioKand that the work will be done in accordar c6 with San Joaquin county ordinances, slate laws, and rules and regulations of the San Joaquin Local'Health District. X_ 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 inIsuch manner as to.becorne subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:;'1 Certify that in•4he�ormance of the work for which this-permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The ap • must II for all required i ction Com a drawing on se side. Signed X____ Title: r P /.V- 9 Date: OR.DEPARTMENT USE ONLY Application Accepted by l - Date Area r�� Pit or Grout Inspection by ___ ii Date Final Inspection by_T4&2?n Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104- ❑Tracy 835-6385 k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI INFO AMOUNT DUE '1 AMOUNT REMITTED CASH CK RECEIVED By DATE PERMIT NO, ) ..EH 13.20 �1 EH 1�-Ze(REV.1,x 51 �Q r L/ J