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rr _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) J 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. �` �f Job Address f ��'�S 6 City L�^�n'" Lot Size PM _ tiL 4Nlair� -� rN j C +. Owner's Name Address f j Phone k Contractor �� L Address 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 { FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom za Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private L] Gravel Pack ❑ Tracy Type of Casing Specifications FPublic ❑ Other ❑ Delta Depth of Grout Seat Type of Grout I I Irrigation __.Approx. Depth i 1 Eastern Surface Seal Installed by Repair Work Done 13 Type of Pump H.P. �__ State Work Done _ _ Well Destruction 0 Well Diameter Sealing Material (top 50'1 _- Depth Filler Material 18elow b0') C TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 . REPAIR/ADDITION I I DESTRUCTIONN (No septic system Permined if public sewer is v, vailable within 200 feet.) r Installation will serve: Residence_ Commercial— Other 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. D Method of Disposal J� t Distance to nearest: Well Foundation__ Property Line f r LEACHING LINE ❑ No. & Length of lines _ Total lengthlsi2e ___ _ T FILTER BED ❑ Distance to nearest: Well f=oundation ___ Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl 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 Di1trict. 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X ~ C�•� Title: fr1 Ly a'�' fL Date: (- � I FOR DEPARTMENT USE ONLY Application Accepted by C,�(.� -._,. Data a --7 Pit or Grout Inspection by Date Final Inspection by / / Date`` r // Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71134 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. a EH 13-24 MEV,r n b} EH 14 26 J J r �}