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^ '{ APPLICATION FOR PERMIT _. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., 'STOCKTON, CA , �, � r Telephone (209) 466-6781 �"�" `' PERMIT EXPIRES V YEAR FROM DATE ISSUED rNVIRQf,l BTAL HEALTH (Complete in Triplicate) FERfAIT/SERVICES 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. { I Job Address City Lot Size PM Owner's Name Address 144Phone r Q��_ Address Contractor „ a6 4�,� L'Yc�nse No.��Phone TYPE OF WELL/PUMP: W 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 1-1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing Domestic/Private ❑ Gravel Pack L3Tracy Type of Casing Specifications M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout ^ 1 E I Irrigation _..Approxi De th l I Eastern Surfage Seal Installed by {V1•� Repair Work Done ❑ Type of,Pump H.P. / State Work Donac Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRlAODITION I I DESTRUCTION i l (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: 'Residence Commercial— Other Number of living units: Number of bedrooms i Water table depth Character of sail to a depth of 3 feet: p SEPTIC TANK ❑ Type/Mfg Capacity .. No. Compartments PKG. TREATMENT PLT” ❑, 9 - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &1Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f I Depth Size Number I SUMPS ❑ Distance to nearest: Wel! Foundation Property Line DISPOSAL PONDS 171 —I-Kaateby 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 r employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 applica must call all required inspections. Complete drawing on raver e. Signed X Title: Date: ti/J JVD I FOR DEPARTMENT USE ONLY Application Accepted by Date 122:1Area _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. b INFO �J CASH i + EH 13-24(REV.5 i H 5) '15 EH 14-2s