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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 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,.. cr / Job Address City ! 1' f l if Lot Size PM Owner's Name OX/'�� f� -Xadress � J �!r � �j l�� .1 Phone Contractor Address "" License No. .3� � j Phone .- T F WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO-NEARES : IC TANK SEWER LINES DISPOSAL FLD. PROP r + FOUNDATI AGRICULTURE WELL OTHER WEL PITS/SUMPS INTENDED USE ;+ TYPE OF WELL PROBLEM ONSTRUC CIFICATIONS c ❑ Industrial ❑ Open Bottom ❑ Manteca . 0 e vation Dia. of Well Casing ` ❑ Domestic/Private __El Gravel Pack ❑ Tr Type of Casing Specifications I f] Public ❑ Other ❑ Delta Depth of Grout Seal a of Grout _ E 11 Irrigation pro x. Depth Il Eastern Surface Seal Installed by _ l Repair Work Done Type of Pump H.P. State Work Done_ 1 Well D tion f ❑ Well Diameter Sealing Material Stop 501 i Depth Filler Material l8elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'jl REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is - ? R 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 g 7.:' Capacity �` r/�) No. Compartments ? PKG. TREATMENT PLT. ❑ Method of Disposal z + Distance to nearest: Well � Foundation '�7-/ Property Line f _ { LEACHING LINE 0 No. & Length of lines /-, C."' / ' Total length/size: FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I`I Depth 3 Size �� Number �. SUMPS 0 'Distance to nearest: Well?-L-- Foundation- *'' Property Line "a DISPOSAL PONDS ❑ f 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._ j' 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 f certifies the following: "I certify that in the performance of the 4 ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws ofCalifornia." The applican must call for all requirdd inspections. Complete drawing on reverse side. y J j Signed X _ Title: i r Date: FOWDEPARTMENT USE ONLY ' T I Application Accepted br'' w� 1�;-'ft-^•� r Date ,��j r Area Pit or Grout Inspection by Final Inspection by Date y1 � r Additigrial Comments: ~' ` ❑ Stk 466-6781 -—"❑ Lodi 369-3621 0 Manteca ''823-7104 ❑ Tracy_ 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CA$H RECEIVED BY DATE PERMIT NO. EHEN 13-24 11-�IREV.1/N5I > _ T,7o-. ;7 .�•iiy�� =� �, �0