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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" s 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 TZ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) x w District for a permit to construct and/or install the work hdescribe is Application is hereby made to the San Joaquin Local Health �� 't) oaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules � � 9 Local Health District. Joh Address I S> City Lot Size PM Owner's Name �� I�(r77rrt4$9dress . n �txSCTe� ��?� Phoneme_. l Contractor�[[�iQt �X/�/of��d'� -Address s ansa No, hone '8 TYPE OF WELL/PUMP: NEW WELL PQ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER )d i Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t 5 . FOUNDATION _10� AGRICULTURE WELL OTHER WELL- .50 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r Industriaht'�Qn+' "'"4❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ut�tt e ❑ Domestic/Private ❑ Gravel Pack �1 Tracy Type of Casing & A/C, Specifications I`I Public (A Other ❑ Delta Depth of Grout Seal Il!�l Type of G>rout1111Z,*& . I I Irrigation 3.-Approx.-Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameler Sealing Material (top 501 Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION {'l REPAIRIADDITION l I DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) / s 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 No. Compartments SEPTIC TANK E] Type/Mfg Capacity P PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i c LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line � r SEEPAGE PITS i I Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must tali for all required inspections. Complete drawing on reverse side. / Signed X Title: [A Date: FOR DEPARTMENT USE ONLY Application Accepted by Rate Area f Pit or Grout Inspection by7AJ Date Final Inspection by Date Additional 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, Stk., CA 95201 4 FEEgMOUNT DUE AMOUNT REMITTED CK EC IVED BY DATE PERMIT NO. )NFO (� CASH( ``qq (� G `'� I + EH 13- IREV.r/n51 EH 24 Iv 0 1� UA V I