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r r i' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ (Cornplete in Triplicate) c Application is heieby 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. 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _ p City f �— Lot Size – PM �+ Owner's Name / Address __.... Phone Contractor ' Address RIA_ ___License No. _ _._Phone TYPE OF WE.L/PU P: _ NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L SYSTEM REPAIR'rte 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 C, industrial O Open Bottom G Manteca Dia. of Well Excavation Dia. of Well Casing D.Domestic I Private O Gravel Pack C Tracy Type of Cas ng . ------ Specifications FI Public f Other Ll Delta Depth of Grnut Se51 " _. Type of Grout __ I I Irrigation . —Approx. Depth , t I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P, State Work Done_ n .. Well Destruction Well Diameter Sealing Material {top 501 Depth Filler Material (Below.50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION 1 DESTRl7CTIONl1 (No septic system permitted it public sewer is available within 200 feet.) U Installation will serve: Residence.. Commercial __ Other Number of living units: Number of bedrooms 3 'r ` `� Character of soil to a depth of 3 Feet: Water table depth / SEPTIC TANK D Type/Mfg .. a .._..... _ _v..__ Capacity) No. Compartments f PKG. TREATMENT PLT. ❑ Method of Di r 'i sposal Distance to nearest: Well s„2/ Foundation Property Line LEACHING LINE D No. & Length of lines _ _ - f . ._. Total lengthlsize 4E FILTER BED ❑ Distance to nearest: Well �.__ Foundation.. .t�a :_'Property Line SEEPAGE PITS I 1 Depth Size Number. SUMPS Ll Distance to nearest: Well Foundations Property Line DISPOSAL PONDS D 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, 1 shall not employ any person in such manner as to become subject to'workman's compensatton laws.of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued,I shall employ persons subject toworkman's cornpensa- tion laws of California." The applicant must call for all required inspections, Complete drawing on revs, a side. fffJ��,�__ � 6 Signed X �(t �Yf/"" Title: Date: �E( _. a ORD �ARTM NT U E ONLY-, � - -- Application Accepted by` - �J�� • -----__ Date __`_ Area ! __ j Pit or Grout Inspection by - - Date Final Inspection by y Additional Comments: 0 Stk 466-6781 D Lodi 369.3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. r EH1 3-24(REV,1I H 5) V 1 EH 14 2a ♦ / �/ d