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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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 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. Job Address U.3 City J Lot Size PM Owner's Name t/ t Address/Y.7 0 4v& 40,,. Phone 1 -7`r r d Contractor L Address 6 4 /J-UOuv License NoA �--3 73 Phone 962 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 j Specifications M Public F1 Other n Delta Depth of Grout Seal Type of Grout Irrigation ___---Approx. Depth I I Eastern Surface Seal Installed by t _ Repair Work Done L-:;r- Type of PumpH.P. /�� _ State Work Done Wel! Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RLIIAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other d Number of living units: Number of bedrooms ; � �a� Character of soil to a depth of 3 feet: S Water t p #�•J SEPTIC TANK Elpartm Type/Mfg Capacity No. Co ents PKG. TREATMENT PLT. ❑ r. Method of� sah Distance to nearest: Well Foundation Property Line ' +► �i LEACHING LINE ❑ No. & Length of lines Total length/size ENVIRONMFNTAt FILTER BED ❑ Distance to nearest: Well Foundation Property Line PERMIT/$ RVICES , SEEPAGE PITS t I Depth Size Number e SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ + t 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: __ 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." The applicant ust cjol for all requ" d inspections. Complete drawing on reverse side. g y(}p Signed X Y'�`f � r Tltla: 1 Date: t `�- 7�O 1 FOR DEPARTMENT USE ONLY f Application Accepted by _ Date �- h / Area `^' Pit or Grout Inspection by Date Final inspection b ©ate Additional Comments: ❑ Stk ,466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. ♦.EH 14-24)REV. EH 11-28 AS "�