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f t . N,J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA f Telepllohe (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED E (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 i 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. e Job Address" J. / !V C,,z6 CityLot Size PM Owner's Name � �J — Address Phone 2 6.2 911 Contractor � 1License kPhone _ / / u � / � Tlllz TYPEOFWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ w 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 Pack ❑ Tracy Type of Casing i Specifications 'I F"1 Public D Other r ❑ Delta Depth of Grout Seal Type of Grout r. I I Irrigation Approxi Depth I 1 Eastern Surface Seal Installed by t ` Repair Work Done ❑ Type of'Pump H.P. State Work Done ` Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITIDN I DESTRUCTION INo septic system permitted if public sewer is avail le withi 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Al Character of soil to a dept of 3"feet: Water table depth SEPTIC TAMC 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 SEEPAGE PITS I I Depth Siz$ '`" Number SUMPS E Ll Distance to nearest: Well. Foundation Property Line DISPOSAL"PONDS ❑ ' M„ 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: "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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call f all requ ed inspections. Complete drawing on reverse side. Signed X l b Title: . date: _ ��`' 0 } FDEPARTMENT USE ONLY Application Accepted by Date Area / p go Pit or Grout Inspection y Date Final Inspection by L, �j DateQ 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 CK 44 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7"NO. r+.EH 1324(REV.1/H 51 / i EH 1a-28 �� -� (J ] i