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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �S 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1,.• k (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. " Job Address /L �4 /[`!O!', �Q X�s d PM j P .f City Lot Size Owner's Name C / tj��d �' . (�C'$-4 Address hT G€ Phone Contractor Address -S Q License No. 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 C FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS INTENDED`-USE TYPE"'OF•W ELX ^""PROBLEM Affg�—CONSTRUCYION SPECIFICATIONS 'T ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ uType of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth f Filler Material (Below 50')--. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJDESTRUC ON f o septic system permitted if public sewer is U I ailable within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms r ' Character of soil to a depth of 3 feet- SEPTIC table depth TANK ❑ Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Weil Foundation Property-Line i I i LEACHING LINE ❑ No. & Length of lines t Total length/size FILTER BED ❑ Distance to nearest:; Well Foundation Property Line v 1 I` SEEPAGE PITS ❑ Depth Size i Number SUMPS ❑ Distance to nearest:. ', Well Foundation Property Line DISPOSAL PONDS. ❑ i 1 t 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 tion laws of California." issued, 6 shall employ persons subject to workman's compensa- ' The applicant must II for all re spections. Complete drawing on revs ids. Signed f - . -. 1- -..r _ 547 Title: Date: �"/o-1? F FOR WA M ENT USE ONLY _ Application Accepted by Date o2 r Area Pit or Grout Inspection by Date Final Inspection by J-7 r Additional Comments: ❑ Stk 466-6781 1. ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835546385 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 INFO RECEIVED BY DATE PERMIT NO. +EHT324/REV.1�9 51 �7 EN T428 do - "'p ��