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�^ - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT NJ() r- 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED NO r (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 incompliance 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... LOwner's ddress 1 City Lot Size PM , �r �} 0 3-_©7h Name � J Address Phone` .� e- &ew �License No.�[ Phoneector r��/ Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:-,SEPTIC TANK SEWER LINES DISPOSAL FLD. . I FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC PECIFICATIONS I EJIndustrial- ❑ Open Bottom EJManteca Well Excavation Dia. of Well Casing ❑ Domestic/Private LnOther avel Pack ❑ Tracy Type of Casing Specifications M 1 Public elta Depth of Grout Seal Type of GroutI Irrigation MApprox pth l I Eastern Surface Seal Instal]ed byRepair Work Done ❑ Pump H.P. State Work Done Weil Destruction ❑ Well Diameter. Sealing Material (top 501, I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCT( (No septic system permitted it public sewer is C vailable within 200 tees.! I installation will serve: Residence_� Commercial_ Other Number of living units Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ' ^❑ Distance to pearest: Well Foundation Property Line SEEPAGE PITS ( I Depth 1 Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑. 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 Di§trict. 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 subcontracting 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 must for all re fired inspe ions. Complete drawing on r reverse side. c5� 3fSigned X Title: Date: t ORDEPARTMENT USE ONLY Application Accepted by Q � Date _3 r-Q>R) Area I Pit or Grout Inspection by Date Final inspection by 1_1�4 '�/ Date Additional Comments: I ❑ 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 i IFEE NFO AM UNT DUE AMOUNT REMITTED CASH RECEIVED sy DATE PERMIT'NO. +.EH 13- (REV.t/>+5) S- EH 14-M-M 2B J O