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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 J quin Local Health District, L'ov jfob nrl1. V l 7" qm_k l_ %14� City / ` A; 11 Lot Size _ � �Z'"'" _ PMI. 7 1/my, �^,�^ AMOUNT DUE Owner's Name rG dres_ s - _ Phone DATE PERMIT'NO. IF _ �J -75— Contractor; License EEo 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public ❑ Other F Delta Depth of Grout Seal Type., of Grout I I Irrigation --Approx. Depth -1.1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction \ ❑ _ Weil Diameter Sealing Material (top 50'I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I r3 Installation will serve: Residence `Commercial __ Other Number of living units: Number of,bedroo s Character of soil to a depth of 3 feet: 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 ❑ No. &Length of lines 1-0 Z/V Total length/size FILTER BED ❑ Distance to nearest: Well 1 Foundation Proprty_Line"_'� SEEPAGE PITS I i Depth Size ` - `s- Number SUMPS Id- Distance to nearest:-- Well ' , Foundation lar9 Property Line DISPO9'AL PONDS ❑ r--r'rf� 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. J 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 shalt notes employ any person. in'such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature•` y j certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ person"ubject to workman's compensa--'f tion -laws of California." " r 'The.app icant-mu' cal or all rl,ired ins tions. Complete drawing on reverse side. Signed X r Title: - Date: DEPAMENT USE ONLY Application Accepted by Date Area ,Pit or Grout Inspection by ; Date Final Inspection by Date Additional Comments: I `s_ 3 I - L1 Stk 466-6781 LJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0 *1. IN t EH 13-24 (HEV. I i e 5) EH 14-26 Box 2009, Stk., CA 952/01 FEE AMOUNT DUE AM T REMITTED •..�`RECEIVEO BYE DATE PERMIT'NO. INFO ,CASH — a