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- i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZELTON AVE., STOCKTON, CA 11 Telephone f2091 466-6781 I PERMIT EXPIRES TYEAR FROMIDATE ISSUED (Complete in Triplicat'e' ) I Application is heteby 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. l Joh Address 40,m Gr�, llv City Lot Size PM Owner's Name Address Phone lS� Ms AddreLicense Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENi4 ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHERPITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON ST5�ONSPECIFICATIONS ❑ Industrial ❑ Open Bottom , ❑ Mantecaa. of Well Excavation ...."-"--.. -. ..-. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing IM Specifications ; r f"] Public ❑ Other Delta Depth of Grout Seal Type of Grput I I Irrigation �_A Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ pe of Pump H.P. «`` State Work Done mm Well pestructio ❑ Well Diameter Sealing Material (top 501 ! j Depth Filler Material (Below 50') M TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_m-.__ Commercial_ Other �• '1 Number of living units: Number of bedrooms .a,, .J Character of soil to a L depth of 3 feet: f J Water table depth SEPTIC TANK ` ❑ Type/Mfg Capacity�� No. Compartments PKG. TREATMENT PLT. El Method of Disposal r Distance to nearest: Well ''T Foundation" � """ Property Line LEACHING LINE ❑ No. & Length of lines M Total length/size ' FILTER BED ❑ Distance to nearest: Well Fo dation--1 Property Line $ SEEPAGE PITS I I Depth Size`, `N Number SUMPS ❑ Distance to nearest: Well Foundation Me ' ' Property Line DISPOSAL PONDS ❑ I I hereby certify that i have prepared this application and that the work will be done in a� cordance 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for all required i spedtions. Complete drawing on reverse side. Signed Title: Date: M FOR DEPARTMENT USE ONLY Application Accepted by –Date Area d Pit or Grout Inspection by ` (� Date � t Final Injection by � _� � • Date L� Additional Comments: — i� 1 `�� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy'C1 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. CJ