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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA � s Telephone (209) 466-6781 i PERMIT EXPIRES 7 YEAR FROM DATE ISSUED 1G (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 l4?eJob Address 'iJ J r✓>�t City Lot Size PM Owner's Name Address c �amr Phone Q :Contractor Address v License No. Phvne �7i� ,TYPEfOlF WELL/PUMP: NEW WELL ❑ WELL RE AGEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI N SYSTEM REPAIR ❑ ER ❑ IS j DISTA CE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE �I FOUNDATION RICULTURE WELL OTHER L PITS/SUMPS 1 �} I� INTt�DED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPE CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excav on '''�a a. o' UVell Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ f Casi Specifications +❑ Public ❑ Other ❑ Delta Depth rout FSeai��rri�. Type of''Grout tt f❑ Irrigation �4pprox. Depth ❑ Eastern ace Seal Installed by ! ;Repair Work Done ❑ Type of Pump H.P. � StatesWork Done .— - ��■----- ' Well Destruction El Well Diameter Baling Material flap 50`1 Depth Filler Material (Below 501 �. (TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ +DESTRUCTION'' (No septic system permitted if public sewer is _available within 200 feet.) R Installation will serve: Residence _Commercial_ Others._ - 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 51 �,- Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Lengthj'of lines Total length/size ^� ,FILTER BED L1 Distance to nearest Well Foundation Property Line �1 SEEPAGE PITS ❑ Depth Size Number kSUMPS ❑ Distance to nearest: Well Foundation Property Line ;DISPOSAL PONDS ❑ it hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 7rules and regulations of the San Joaquin Local Health.District. 1 `Home owner or licensed agent's signature certifiesthe following: I certify that in the piformance—of the"workfor wtiichNrs pe mit 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- . �5tion laws of California." The applicant must cal for all required i frac ions. Complete drawing on reverse side. p, !Signed �1' � � I�� Title: ,/+ M- . e Date: -/ Cn� �j FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by DateFinalFinal Inspection by Date ��Additional Comments: ?_/ 1 ,.2&] f;❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 ' n licant.—Return -copies,to:rEnvironmental_Health Permit/Services 1601,.E._Hazetton�Ave P-:O:-Box-2009,RStk.,„CA..95201 r -�`-`--"""”" ..app a th Per l FEE AMOUNT DUE AMOUNT REMITTED yi 1,,CKf ' RECEIVED BY DATE PERMIT*NO. j" INFO H + EH 13-24(REV.1/m5) Q Cl S V �. f C r EH 14-28 ��' �� ✓ ! 1