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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ,5 Telephone (209) 466-6781 oK PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to the San Joesaquin Local Health District for a permit to construct and/or install the work herein dee applica on is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I} ob Address r l L C � City S f d t.+c)�l` Lot Size PM � I� J , �1 L l �• �r' Phone ! Y�S f Owner's Name Address V1� Cd��rs� 4 I Contractor Address License No. Phone TYPE OF WELL/P P: NEW WELL ❑ WELL.REPLACEMENT C3 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 0,Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r I'1 Public n Other { Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by - State Work Done i Repair Work Done 0 Type of Pump H P• - Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 1 Filler Material (Below 501 TY -- PE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION ( I DESTRUCTION (No septic system permitted if public sewer is y.� I available within 200 feet.) Installation will serve: Residence Commercial_ Other ,~ r � 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 I PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line '1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line {��\ SEEPAGE PITS I I Depth I Size _ Number " J SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ + 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." i The applicant ust call for all required inspections. Complete drawing on reverse side. l / � Y/� Signed X Title: Date: n R DEPARTMENT USE ONLY [ Application Accepted by �1.n `V�_- �^ —. Date fea 1 Pit or Grout Inspection by )]ate Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t I FEEhIMOUtDUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT'ND. CASH i1 EH 1 3-24 IREV.1/H 5) TSf EH 1429 1 61 L