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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZE T ON AVE., STOCKTON, CA 1\J0 Us Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED TVA i (Complete in Triplicate) ` Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d scribed. This application is a 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 E Local Health District. Job Addressdd lit y� City Lot Size pIV1 Owner's Name nw, i Address Phone � _ �3� s Contractor � �� s �� Address License No.19 l® Phone 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 S SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI NS ❑ Industrial ❑ Open Bottom ❑ Manteca "'"Dia. of We vation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ° n5lLof Casing Specifications f`l public ❑ Other 17,Delt Depth'of Grout Seal { $ Type of Grout •w, t i S� 3J T I f Irrigation _._Approx. Depth astern Surface Seal Installed b _ Repair Work Done ❑ Type of Pur. �'F! P. State Work one C Well Destruction LJ Well Diameter{ Sealing Material (top 50') Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other f Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: 1 Water table'depih' SEPTIC TANK ❑ Type/Mfg Capacity No. Campartmenis V PKC. TREATMENT PLT: ❑ i Method of Disposal 17—_ Distance to nearest: Wella Foundation Property Line " t � i 1 I •"fa LEACHING LINE ❑� No..& Length of lines f � Total length/size I r 1 ? •FILTER BED ❑ Distance to nearest: ' WeIJ I Foundation ; Property Line ' Q SEEPAGE PITS I I Depth ( r Size _ Number t r SUMPS ❑ Distance tol nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with 5an'Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ?� 1,rtI '�"a .\ , 1 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." Contractors hiring or sub-contracting signature I 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." 1. r i r �" I The applicant m call for all required ins ections. Complete-drawing-on-reverse-s1der- - Signed X Title: CZ°"t. Q .2 Date• FO DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date_ Final Inspection by Date Q Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 CK 4 i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY p DATEGJ PERMIT'NO. EH + EH t4 29( REV,