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APPLICATION FOR PERMIT �S�'!n � SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 E. HAZEL i ON AVE., STOCKTON, CA ' Telephone 12091 466-6781 "W' D ' r . 1' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOV a ��$� (Complete in Triplicate) ENVI RQJIN �NpJam• A_LT;bjApplication is hereby made to the Sahlioaquin Local Health District for a permit to construct and/or install the work + + rs made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules� rltiIn Joaquin Local Health District. I I r Job Address 13 1 '�S�`� :S "�°n City Lot Size PM Owner's Name J 4 J Address -��.�'-� ��r — Phone P 4� p ` Contractor Address A e.� License No/_� Phone TYPE OF WELL/PUMP: ! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION L7 \ SYSTEM REPAIR OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED-USF TYPE OF WELLb-PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �[)ia INeH-Casing ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of;Casing Specifications FI Public C-1 Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation _.-Approx. Dept I I �astem Surface'Seal Installed by - r /k,� H.P. Repair Work Done Ca- Type of Pump �f•� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'I t),3 Depth Filler Material (Below 50') k TYPE OF SEPTIC WORK: NEW INSTALLATION 1") REPAIR/ADDITION E I DESTRUCTION I I {No septic system permitted if public sewer is V\ Yf available within 200 feet.) r Installation will serve: Residence Commercial— Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments.' > > - PKG. TREATMENT PLT. ❑ . _ Method of Disposal' R Distance to nearest: Well Foundation - Property Line `€ / LEACHING LINE ❑TM No. &Length of lines Total le`gth/szi e'` f FILTER BED ❑ Distance to nearest: Well Foundation Property!Line SEEPAGE PITS I'] Depth Size Number ! SUMPS LI Distance to nearest: Well Foundation Property Line }1 l DISPOSAL PONDS ❑ A ! 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 applicat t st all for ail required inspections. Complete drawing on reverse side. r i Signed Dots: .Y-3a R FOR DEPARTMENT USE ONLY r Application Accepted by ______ _ `� •• �D.ate_ --- Pit or Grout Inspection by Date Final Inspection hy /� �_ Date Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 r r CK AMOUNT RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED CASH + EH 13-24 1REV.i/n 51 _)L-'7� EH t4-28