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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—i ON AVE., STOCKTON, CA I 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 n County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. - w y City.., Lot Size A�� PM Job Address ' Owner's Name pff Address � l'L7F��._ Phdne Contractor _ Address �� ) w S License No. Phone �. TYPE OF WELL/PUMP: NEW WELL 71WELL REPLACEMENT ElDESTRUCTION X' PUMP INSTALLATION r7SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE N FOUNDATIOAGRICULTURE 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. ♦ Sp ecifications ❑ Domestic/Private 11 Gravel Pack ED Tracy Type of Casing F] Public ❑ Other I El Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth El Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material [Below 50`? TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ID DESTRUCTION a o septicailable within system permitted if public sewer is Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet::I Water table depth SEPTIC TANK L] Type/Mfg F Capacity No. Compartments PKG. TREATMENT PLT. ❑ ! Method of Disposal 4 Distance to nearest: Well Foundation Property Line l LEACHING LINE ElNo. & Length of lines Total length/size FILTER BED ❑ ,Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 11_ Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ s r 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 Il rules and regulations of the San Joaquin Local Health District. that in the performance of the work for which this permit is issued, f shall not Home owner or licensed agent's signature certifies the following: "I certify 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 st call for all 'red inspections. Complete drawing on reverse side. 16 Title: Date: Signed • jam(✓ FOR DEPARTMENT USE ONLY' l p� Date �� 0 ?5 Area Application Accepted by I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Vtodi 369-3621 ❑ Manteca 823-7104 .❑ Tracy 835-6385 Applicant- Return all c s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUI: AMOUNT REMITTED RECEIVED BY DATE PERMITNO. INFO / i Y CASH j J� CA— + EH 13.24(REV.1/861 - L.J� ` �7 Q 1��t,p ��-'t tG '� � 7 EH 1426