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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA t Telephone (209) 466-6781 F `PERMIT EXPIRES TYEAR FROM DATE ISSUED } (Complete in Triplicate) Application is he+eby 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. or:zCitys D Lot Size PM Job Address , /y] Address 6 I yo Phone ��! Owner's Name fy� ��/ 'J1n'i• 1 !d�,lrs, / C® l/ Contractor Address ; icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ r DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES ' -DISPOSAL FLD. POOP. LINE —� FOUNDATION AGRICULTURE W L; OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A A CONSTRUCTION SPECIFICATIONS i ❑ Industrial [7 Open Bottom g ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing '� 4 Type of CasingSpecifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy FI 1 Public hl Other J Cl Delta Depth of Grout Sea! Type of Grout — I 1 Irrigation prox.'Depth l 1 Eastern Surface Seal Installed by - Repair Work Done ❑ pe of Pump —-P-fi.Pr '"' - - " State Work Done r Well Destruction Well Diameter Sealing Material [top 50'1 Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1.1 .•DESTRUCTI I.(No septic system permitted if public sewer is t available within 200 feet.) 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 `") Ca acity No. Compartments ` SEPTIC TANK ❑ Type/Mfg. P PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS l I Depth I Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I Y 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, l 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 regpections. Complete drawing on reverse side. X Signe Title: — Date: /� \ FO If DEPARTMENT USE ONLY �n.�.r�C]ti.�� _ Date Area Application Accepted by - � - l 7 F I' Date Final Inspection by Date Pit or Grout Inspection by r .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 IglyIOUNT DUE MOUNT�REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24IFtEv.1/1451 �$ f zi� r �� ,J EH 14-26 d -