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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZE T ON AVE., STOCKTON, CA f , Telephone (209) 466-6781 4 PERMIT EXPIRES TYEAR FROM DATE ISSUED ` (Complete in Triplicate) Application is heoeby 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 City Lot Size �/ PM r Iti el i! Owner's Name Phone �d�� Address /�.7�S � .�^�/ /l� Phone • Contractor f¢�a� t Address License No. Phone— TYPE hone_TYPE OF WELL/PUMP: _ , 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 13 Open Bottom I- O Manteca Dia. of Well Excavation Dia. of Well Casing r r ❑ Domestic/Private ❑ Gravel Pack t ❑ Tracy Type of Casing Specifications k M Public ❑ Other Cl Delta Depth of Grout Seal Type ype of Grout I 1 Irrigation __._".Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump j•- H:P E State Work Done_ I Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth ; Filler Material {Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION I I DESTRUCTIO f septic system permitted if public sewer is ilable 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 ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. El f Method of Disposal k� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines" Total length/size_. FILTER BED ❑ Distance to nearest: Well TFoundation Property Line SEEPAGE PITS I ] Depth a Size Number SUMPS D 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 i 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 ust call for all requird inspections. Complete drawing on r arse side. Sig? Title: Date: �) % �l r FOR DEPARTMENT USE ONLY Application Accepted by V Date Area Pit or Grout Inspection by date Final Inspection by Da Additional Comments: \,j LIStk 466-6781 ❑ Lodi 3621 ❑ Mante 823-71 El racy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, 5tk., CA 9 1 t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY. INFO DATE PERMIT NO. + EH 13-21[HEV.tiR5Y Zj� �„ 7 : 67—/9