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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR`FROM DATE ISSUED ' (Complete in Triplicate) t 1. r_ y _ I 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 Ryles and Regulations of the San Joaquin Local Health District. ` �' _ City Lot Size � PM Job Address fA et=. ,., :. i. Owner's Name Address 82Ga!fLa''� - Phone Contractor_ �1 J "�'� Address G�►► f /:� - License No. -"-� Phone 2S2! r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1- _ W DISTANCE TO NEAREST: SEPTIC TANK —" SE1rVER LINES ";az , ""� DISP05 L FLD"-� r �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 T Dia. of Well Casing l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ElPublic ElOther t LlDelta Depth of Grout Seal Type of Grout ElIrrigation ---Approx. Depth [:1 Eastern Surface Seal Installed by ! ' Repair Work Done Y Type of Pump H•P. / State Work Done I Well Destruction ❑ Well Diameter., Sealing Material (top Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) h Installation will serve: Residence_ Commercial Other_ Number of living units: Number of bedrooms, V f Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg If Capacity No. Compartments PKG. TREATMENT PLT. Ll {.y £ '� Method of Disposal Distance to nearest:„,F Well Foundation Property Line ¢� V LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS' _ ' ❑ ;QeptFi'” _"_ Size--7_,Number #` SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 l rules and regulations of the San Joaquin Local Health District. r 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,I shall employ persons subject to workman's compensa- tion laws of California." I The applicant njust call for all required inspections. Complete drawing on rev a si e. Signed X1 �-^�"" Title: Date: ~ * F EPARTMENT USE ONLY y „ iy Application Accepted by Date Area Pit or Grout Inspection by Date Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 365-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTEDC RECEIVED BY DATE PERMIT N0. 4 I INFO C�7 + EH 13-24{REV.1/9 5) 3 [,7U 3 S-C V � 17 y ~/� �1✓ . EH 14-26