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j 9 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 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 j Local Health District. r t b q wl- L"art✓ l7 Kd r ]yf� C tA�s PM Job Address �` 4/ �City Lot Size �/ � I Owner's Name 4 �U�, ,42 r Y?1C1(`]L Address �1 7 �fJ �• � C Phone �1 �p IF- ,-..-.� ..— ..--w"` - -"�_-t "'� License No. Phone- --- Contractor Address` TYPE OF WELL/PUMP: ,NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION. OTHER ❑ PUMP INSTALLATION ❑ i SYSTEM REPAIR ❑ t 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 r Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing s Specifications F] Public n Other Cl Delta Depth of Grout Seal r Type of Grout I Irrigation --Approx. Depth i 1 Eastern Surface Seal Installed by'r� ~� Y - Type of Pum H.P. State Work Done Repair Work Done ❑ yp p .� Well Destruction ❑ Well Diameter Sealing Material (top 501 # Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11. REPAIR/ADDITION 1.1 DESTRUCTION l I (No septic system permitted if publ' ewer is f available within 200 feet./ w installation will serve: Residence ra Commercial_ Other 1 Number of living units: Number of bedrooms Characterofsail to a depth of 3 feet: Water ie depth _ SEPTIC TANK El Type/Mfg Capacity . Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to n Well Foundation - -.PropertyL tine LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well "Foundation Property Line SEEPAGE PITS I'] Depth Size Number SUMPS ❑ Dist o nearest: Well Foundation Property Line 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 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 m)1st call for all required i pections. gomplete drawing on reverse side. Signed X e [ Title: Cb LU,7?0T Date: r FOR DEPARTMENT USE ONLY r I Application Accepted by Date Area Q Pit or Grout Inspection by Date Final Inspection by Dateof Additional Comments: a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. INFO ♦ EH 3-241NEV.rin5 / ,�4,36 -7 ✓ -7,3 I EH 14-28