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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 'r'n Triplicate) Application is heieby 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. c �G. Job AddressCity r�U r Lot Size PM Owner's Name .0 hA L. 6 p,�- _ Address Phone Contractor 1 r �� Address /✓jfLal4License NoA�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` 1'1 Public Cl Other A ❑ Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation --Approx.. Depth I I Eastern Surface Seal Installed by 7 Repair Work Done ❑ Type of Pump H.P ' t ' State Work Done_ Well Destruction ❑ Well Diameter Sealing Material ltop 501 l - Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is ^-� available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth�- I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Z _ Property Line I r LEACHING LINE 17-1 No. & Length of lines Total length/size FILTER BED Distance lo nearest:' CNell�" "�""""Founiiafion f�G%= property Llne`F'. 1 � r SEEPAGE+PITS i 1 I Depth Size' Number ± SUMPS ❑ Distance to nearest: * Welly' Foundation 1 '' Property Line k 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 j rules and regulations of the San Joaquin Local Health Di1trict. '°-' 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: 10 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa, x. .tion tion laws of California:"*a V►.. The applicant"must call far II,requl ed'inspections.Complete drawing on reverse side. Signed X Date: ' FOR EPARTMENT USE ONLY �i t*_ } 11 Application Accepted by Date Area {Pit or Grout Inspection by Date �I l Final Inspection b f Dat Additional Comments: ❑ Stk 466-6781 -❑ Lodi 369-3621 Cl Manteca 523-7104 ❑ Tracy 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.– . CK ..-�•RECEIVEp:BY^^ + INFO. CASH— i y D'ATE.""'^^..F i�'PERMIT�NO.—" " ..."`"",�""' _. :.EH 13--24-(REV.i EH 14-28