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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 N 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. i. / a t Job Address L r ` [.aU�/�* �IrPM City Lot Size oi `i Owner's Name Address .aC 3 az11 ` mm � 4 Phone Contractor Addressicense No. Phone TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial* --❑ Open Bottom --.,El Manteca- Dia. of Well Excavation Dia. of Well Casing. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`) Public ❑ Other F ❑ Delta Depth of Grout Seal Type of,Grout _ I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump, H.P. State`Work Done Well Destruction ❑ Well Diameter` Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I I DESTRUCTION No septic system permitted if public sewer is _. - -. . .. y available within 200'feet.) Installation will serve: Residence Commercial_ _ Other Number of living units: YNumber of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ j f Method of Disposal : f Distance to nearest: Well ' Foundation Property Line ~ 1■ r LEACHING LINE ❑ No. & Length of lines f , 5 Total length/size FILTER BED ❑ Distance toInearest: Well_ :'Foundation { Property Line i I z SEEPAGE PITS I I Depth ) ' Size _ Number SUMPS ,..,� - .M.,- _ L7 Distance to;nearest: Well Foundation Property Line � DISPOSAL PONDS ❑ 1 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 Di3tiici - -t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is iss ed, I shall not q employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring of sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." c, "' "" "TFie appiicanf must cat!foi'alf i quired'inns�ctions'Complefe i9Pawing on reveFse sideW r'` __ ,y Signed X R Title: Date; Q rAQH DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grou spa tion by Date No �'��' final Inspection bL � 1 v Date Additi nal Comments: V El _ o Stk 466-6781 .❑ Lodi 369-3621 ❑ Manteca 823-71 ra 835-6385 eS, y� { Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200$, tk., CA 95201 I c FEE AMOUNT DUE MOUNT REMITTED C RECEIVED BY INFO ASH DATE PERMIT'No. ♦.EH EH 4 1 -24tREv.i/H51 1v" v� t -2a I