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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA A/0 -Telephone (20.9) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ., , } 1,. (Complete in Triplicate) x c 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. a 7- (l Jab Address City ,F Lot Size T - •• PM � ,fJ ,f Owner's Name/'�N��G �'/� ��L Address T 6V ;'� ' r�9f `� Phone� � Contractor t Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1. SYSTEM REPAIR {❑ OTHER ❑ f y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINN' DISPOSAL<FLD. PROP. LINE FOUNDATION AGRICULTURE ELL -�OTHWELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON RUCTIONtSPECIFICATIONS 3 i ❑ Industrial ❑ Open Bottom ❑ Manteca j�e`pth Dia._of W U,ECxcavation Dia. of Well Casing ❑ Domestic/Private Q Gravel Pack ❑ Tracy p C ing Specifications ❑ Public ❑ Other ❑ Delta of Gr ut Seal Type of Grout ❑ Irrigation ---Approx..Depth ❑7LSealingMateriO ' Surface Seal Installed by Repair Work Done ❑ Type of Pump State Work Done Well Destruction ❑ Well Diameter (top 50') Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT N (N septic system permitted if public sewer is x 1 ailable within 200 feet.) LP installation will serve: Residence— Commercial_ Other s J ~ Number of living units: Number of bedrooms ar Character of soil to a depth of 3 feet:, Water,.table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to-nearest: Well Foundation) Property Line k LEACHING LINE ❑ No: & Length of lines Total length/size FILTER BED ❑ Distance9to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size f� `°Number ' Z, - SUMPS ❑ 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 i ie performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." t4 i icant ss cal�equired i ions. Complete drawing on reverse side. l' Signed r Title: Date: (�'�kJ F EPARTMENT USE ONLY /} Application Accepted by .�� date A /,r - Area V� L Pit or Grout Inspection by Date Final Inspection by Date i d Additional Comments: ❑ Stk 466-6781 -❑ Lodi 69-3621 ❑ Manteca -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 INFO AMOUNT DUE'i AMOUNT REMITTED CASH -RECEIVED BY DATE PERMIT,No. + EEH H 14-241REV.tiw 5) �a �C) �`"-��, �/ BZZ �/ ��