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X13 APPLICATION FOR PERMIT ;r SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON .AVE., STOCKTON, CA Telephone {209) 466-6781 SY PERMIT EXPIRES'l YEAR FROM DATE ISSUED N0�S�04,G� (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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address C Y JPS r� _. - City JR Lot Size PM rp �P Owner's Name Address Phone � r Contractor f d Rddress A License No. -�--L Phone_ r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-la' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t 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 E) Tracy Type of Casing Specifications r (Public f7 Other ❑ Delta Depth of Grout Seal. Type of-Grout I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of PumpH.P. State Work Done Well Destruction ❑ Well D)amoter Sealing Material )top 501 Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I lNo septic system permitted it public sewer is f available within 200 feet.) i 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 t SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments 1 PKG, TREATMENT PLT. ❑ Method of Disposal (� w Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation .Property Line 1 7 SEEPAGE PITS i I Depth I Size Number { SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS L1 `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 follo ' g: "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 Cal or ia." The app lfc t t call for all reqAr d inspect' s. Complete drawing on r or ide. Signed Title: o Date: ` F R DEPARTME T USE ONLY Application Accepted by Date P' t 7 �j Area Pit or Grout Inspection by Date w Final Inspection by pate 3 Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 f ❑ Man ca 3-7104 ❑ rac 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 INFO CASH RECEIVED BY DATE aPERMIT .EH14-241REV.tiHsf 35c ��EH 14-28 S