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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZELTON 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 city 7/?A Lot Size PM G� Owner's Name. Address ' g� � IPhone t � Contractor _ - Address /'7->0, %C7 A License NoA�66� Phone his I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ; PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL- - QTHER WELL P1T5/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing F1 Domestic/Private D Gravel Pack ❑ Tracy r Type of Casing Specifications i] Public C, Other Cl Delta Depfh of Grout Seal Type of Grout I 1 Irrigation _..Approx. Depti I I Easte,ram "Surface Seal Installed by - Repair Work Done lD Type of Pump - - H.P. State Work Done, ; 0 Well Destruction ❑ Weil Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 t ;+ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION ]. I INo,Sept isyst permitted if public sewer is ava0able wim thin'?20o feet.) Other_ _,Installation will serve: "Residence Commercial d - , Number of living units: ' Number of bedrooms , I Character.of soil to a depth of 3 feet: Water able depth ..ti s �No:iCom'artments + SEPTIC TANK ) Type/Mfg Capacity « , PKG. TREATMENT PLT. ❑ i1""�'"'" �i1RrDisposa�_ Prop%rty Line,v t Distance to nearest: Well f Foundation _�-� �,�,,,,,, ,®-�r.. `mss,.:"!" ,s: I LEACHING LINE : No. & Length of lines Tatalrler�gth�lsize�"� r/ g Y - FILTER BED ❑ F Distancetonearest: Well r Foundation �T Property tine �r SEEPAGE PITS I If Depth _Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Liffe DISPOSAL POf OS 0 I hereby certify i�hat I have prepared this application,aQci,that-the work-will-be-done-in-a ea a ,�q^pori 4g014in county ordinances, state laws, and ! rules and regulatofls of the San Joaquin Local Healtti District. Home owner or lidensed agent's signature certifies He following: "I certiWihat:in the performance of the-work-for which this permit is issued, I shall not employ any person in,such manner as to become sGbject to workman's compensation laws of California Contractor's hiring or sub-contracting signature certifies the following:;'(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:,' i The applicant must call,for all rev'regi ctions. Complete drawing onreverse side. � 1 Signed X _T.itle: Date: FOR PARTM USE ONLY _.. - Date, �! Area Application Accepted by Pit or Grout Inspection byDate Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8.35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton tAve., P.O. Box 2009, Stk., CA 95201 PEE AMOUNT DU -...E AMOUNT REMITTED �'SCK- '' FiECEIVED-BY DATE PERMITNO. CASH - EH 13-24(REV. /e 51 -�©yam 197LiQ EH 14-28,