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x O ■ f y V APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 4 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 nl JQ i 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.1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i d �C� , __ City Lot Size PM Job Address , i j;� Owner's Name Address � V6'4 l� L Phone Contractor's Name .�10 License No. Y Phone TYPE OF WELL/PUMP: NEIN+WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El-,,, _ SYSTEM-REPAIR.i?-- " `OTHER ❑ � } -�.DISTANCE TO-NEAREST7SEPTIC TANK f�......_._ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION I 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 2'15omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other :l ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth P Eastern Surface Seal Installed by Repair Work Done -e<Type-of Pump H.P. / State Work Done Gyo Well Destruction ❑ 'Well Di ma eter Sealing Material (top 501 " Depth Filler Material {Below 501 '°'TYPE"OF-SEPTIC-WORK-- NEW-INSTALLATION ❑ -REPAIR/ADDITION-E7 DESTRUCTION-E-tNo septic system permitted if public sewer-is- s - available within 200 feet.) , Installation will serve: Residence. '_ Commercial_ Other Number of living units: Number of bedrooms _�..�. Character of soil.to a_d_epth of 3 feet: Water table depth SEPTIC TANK F] .Type/Mfg Capacity No. Compartments C' PKG. TREATMENT PLT© Method of Disposal Distance to nearest: Well--- Foundation Property Line LEACHINGL- IN ❑ No. & Length of lines r Total length/size FILTER BED t"'litl�Distanee to nearest: ;4Well_- _ Foundation Property Line SEEPAGE-PITS P E3. Depth Size Number _ _ ✓� T SUMPS "�❑ Distance io nearest:'_ Tl T Foundation Property Line i DISPOSAL PONDS ❑ hereby certify that:l.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 ilie San Joaquin Local Health District. F 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•eignature 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." i The applicant"mu call for all lred ' ctions. omplete drawing on raver side. f Signed " 1 Title: S Date: 3 FOR DEPARTNEENT USE ONLY Ap ication Accepted by v yII'v` Date Area - , `/ Pit or Grout Inspection by ! Date ina! Inspection by� Date -d 1 Additional Comments: — ❑ 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 55201 IFEECKNFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PpERMIT`NO. J + EH t3.2a MEV.10/831 p l�Q EH 14-26 _ 1 • vu i