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I APPLICATION FOR PERMIT '1y j# SAN JOAQUIN LOCAL HEALTH DISTRICT UT U R 0": C f 1601 E. I+IAZEL T ON AVE., STOCKTON, CA { OCT Telephone (209) 466-6781 �� I PERMIT EXPIRES TYEAR FROM DATE ISSUftNVIRONMENTAL. HEALTH (Complete in Triplicate) IILNI'IITiS-ER ICES I 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 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 Local Health District. Job Address,, —_,.�O,:;- k — City Lot Size PM Owner's Name Address Phone Contractor 2 &l _ Address & �OT� License NPhone � r-215r,�6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ' SYSTEM REPAIR qN, 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 1-1Open Bottom 171Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1 Other El Delta Depth of Grout Seal Type of Grout _ I I Irrigation _;:Approx. Depth I I Eastern Surface Seal Insstalled'byf - Repair Work Done Type of Pump H.P. 19LL-a-- State Work Done L t Well Destruction ❑ Well Diameter Sealing MateOial-(top 50'1 `t Depth Filler Material (Below 50'I° " ----- TYPE OF SEPTIC WORK: NEW.INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION I I-Wo septic system permitted if public sewer is ,. available within 200 feet.) instAlation will serve: Residence_4 Commercial— Other r .ar_i�Number of living units: Number of bedrooms ,� r Character of soil to a depth of 3 feet: " Water tattle depth l ASEPTIC TANK ❑ Type/Mfg X' Capacity NoCompartmenis ' PKG. TREATMENT PLT. ❑ "r !Method of Disposal I _ . � Distance to nearest:.__ Well Foundation Property Line LEACHING LINE ❑ No. & Length of Iir-es-1 �'�"� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation LLLZ Property Line SEEPAGE PITS I 1 Depth Size Number ' SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ /ti *� I hereby certify that I have prepared this application and that the work will be done i an ccorda_nce with San Joaquin county ordinances,' state laws, ander rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "l,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,%kork for which this permit is issued, 1 shalhemploy persons"subject to workman's compensa tion laws of California." rt^` 1 / The applicant must tail••( II required in actions. Complete drawing on rev rse side. ! ell, Signed �'" Title: Date: g —� v LAJ k F FOR DEPARTMENT USE ONLY Y —!� T Application Accepted by Date f Area Pit or Grout Inspection by - Date Final Inspection by Date // a 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 AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. INFO ! s.EH1324(REV.1/K51 EH N-26 !