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" ! APPLICATION FOR PERMIT pp�yN1 E�D SAN JOAO.UIN 1_66AL`HEAL7H DISTRICT REj 1601 E. HAZE T ON AVE., 'STOCKTON CA I +. Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IVr (Complete in Triplicatefy k r ' ��V�RO MIT VICES p Application is hereby 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 Ryles and Regulations of the San Joaquin Local Health District. +� - ► k r Job Address ' city1 Lot Size PM S Owner's Namad,Pe ;. Address -Phone I� { �- p Contractor ! Address f 7 License No.( ^.moiPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I� PUMP INSTALLATION ❑ SYSTE=M REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES °Y DISPOSAL FLD. PROP. LINE .IJ FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial I ❑ Open Bottorp ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I. Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing Specifications l ❑ Public �� ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 1h --Approx. Depth ❑ Eastern / Surface Seal Installed by Repair Work Done * Type of Pump H.P. IY2- State Work Done Well Destruction ❑ Well Diameter E:° Sealing Material (top 50') - Depth Filler Material 1Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Ili, j' available within 200 feet.) Installation will serve: Residence_I_Commercial— Other Number of living units: NuMber�of bedrooms Character of spoil to a depth of 3;feet: Water table depth SEPTICtlTANK I� ❑ Type/MfgI �: Capacity No. Compartments �.: PKG. TREATMENT PLT. Li 'A Method of Disposal Distanceto nearest: Well Foundation Property Line LEACHING LINE- ❑ No. & Length of lines '{� ' �'�� Total length/size FILTER BED ❑ DistanC'e to jnearest: Well Foundation-- Property Line SEEPAGE PITS : ❑ Depth IT SizeT. T k Number r _SUMPS :I LJ Distance to nearest:" .. _ Well ;Foundation �t Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will 1;e 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." .n The applicant must caJI for all required inspections. Complete drawing o verse side. s SignedTitle: bate: /Yf FOR DEPARTMENT USE ONLY Application Accepted,by , °�,3. � • Date Pit or Grout Inspection by Date Final Inspection by Date II Additional Comments: ❑ Stk 466-6761 ❑ 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 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED CASH + � RECEIIVED SY n DATE PERMIT "NO. I . VAVEH {REV.7/B5) /EH 1426r{f # - - .