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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT it t 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 1�13ERMIT EXPIRES TYEAR FROM DATE ISSUED 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 descri edi application is i 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 If Local Health District. I Job Address O City S�fM "f Lot Size PM r/ c�A>�el D�//jCyt� Address ?Q�� Phone �� Owner's Name — I } Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ is i! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P. LINE FOUNDATION AGRICULT.URE'WELL OTHER WE PITS/SUMPS INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION FICATIONS ❑ Industrial i, 0 Open Bottom 0 Manteca Dia. Excavation Dia. of Well Casing 11 Domestic/Private O Gravel Pack El Tracy Type of Casing Specifications l`1 Public Ll Other elta Depth of Grout Sea! Type of Grout I i Irrigation _A epth i I Eastern Surface Seal Installed by - Repair Work Done ype of Pump H.P, State Work Done 1 Well pest Ion ❑ Wel! Diameter` A Sealing Material atop 50') # Y V Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION DESTRUCTION l 1 INo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence J ,Commercial_ Other Number of lining units Number of bedrooms Character of soil to a depth of 3 feet: Water table depth O SEPTIC TANK' Type/Mfg! Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that k 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 bf the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." f The applicant must call for all required inspections. Complete drawing on reverse side. f Signed X --� �1 Title: Date: i I :! FOR DEPARTMENT USE ONLY Application Accepted b D4by Area ate, Pit or Grout Inspect( Date Final Inspection Date /� Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 cI FEE AMOUNT DUE AMOUNT REMITTEDCASH . RECEIVED BY DATE PERMIT'NO. INFO `J r EH 13-24 IRE'V.t/N 5f 5� r/r a✓S'/ 97-,;4 EH 14-26