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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �v � /J Telephone (209) 466-6781 "` G 1-c PERMIT EXPIRES 1 YEAR FROM DATE ISSUERVIR0114MEN TL (Complete in Triplicate) PERMIT/SERVICES HEALTH Application is heteby 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. 44 A Job Address 'T L. ��( G ' o t-e City 31 Lot Size PM Owner's Name 1 �ti S�G. �ikt='4ddress �[J 1 !./H!�FSC �L hone Contractor -�Address /L �� v License No. �� 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 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public f I Other F1 Delta Depth of Grout Seal Type of Grout _ XIrrigation ---Approx. Depth ! Eastern Surfal Installed by _ Repair Work Done %K Type of Pump �..1S.d H.P. ace State Work Done , ro Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:* `J' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size r n FILTER BED ❑ Distance to nearest: Well Foundation Property Line V} SEEPAGE PITS I I Depth Size r., Number V� SUMPS Cl Distance to nearest: Well Foundation Property Line J DISPOSAL PONDS ❑ - I 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 I� rules and regulations of the San Joaquin Local Health D3trict. ( ` 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 fallowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workm 's co ansa tion laws of California." The a7X ; all required tions. mple drawing on side. Signed ` Title: ,T Date: Q R DEPARTMENT USE ONLY Q Application Accepted by Data `� Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK INFOJf3 OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. ♦ EH 13'24(REV.1/n 5) S EH 1420