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f I APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA f �'1 Telephone (209) 4W- LA ^' 20 r _! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hefeby 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. Job Address CityN Lot Size �® �� PM i Owner's Name /lrG��J Address w"— / Phone --;25 T5S Contractor Address License No. Phone_ II TYPE OF WELL/PUMRJY NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I M Public D Other ❑ Delta Depth of Grout Seal_ Type of Grout I I Irrigation ..Approx. Depth I I Eastern T Surface Seal Installed by d _ _ Repair Work Done ❑ Type of Pump i H.P. State Work Done Well Destruction ❑ Well Diameter f Sealing Material (top 501 Depth { Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR7ADDITION I.I DESTRUCTION (No septic system permitted if public sewer is s available within 200 feet.) Ii Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. D ✓`1! �', Method of Disposal Distance to nearest: Well Foundation Property Line 1 � - LEACHING LINE D No. & Length of lines '— Total length/size FILTER BED ❑ Distance to nearest: Well ,-Foundaiion_ -- - Property Line SEEPAGE PITS I I Depth = Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work ill=,be tdone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di"strict. 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 CaliforAia." 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 lawsof ornia.' — � F The appli ant m st call for all requ' d inspections. Complete drawing on reverse side. i Signed X Title: Date: f j FOR DEPARTMENT..'USE ONLY `'.3 Appli ation Accepted by I, "— � � Date s_ ""Z Area t Pit or Grout Inspection by Date, -` Final Inspection by Date tIS Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca _823-7104 ❑ Tracy 835-6385 Applicant-Return all copies to: Environmental Health Permit/Services 116601,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. ` +.EH13-241REV.fiHs1 EH 14-2e 311Z�:o , 0 Awl � �J7 1