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,r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZETON AVE., STOCKTON, CA r Telephone (209) 466-6781 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 Rues an Regulations of the San Joaquin j Local Health District. �'' �*� ` �- L1Z L Lot Size PM Job Address City aPhone � g w 1 a 's Name � o / o QA Owner Contractor �• ' Address 0�Q t7icense No. 2�— n a_Phone TYPE OF WELL/PUMP: V NEW WELLJK WELL.REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 6n a SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL.- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J �i D Industrial ❑ Open Bottom ( Manteca Dia. of Well Excavation D Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ather Cl Delta Depth of Grout Seal z Type of out Z D(I Erriyation prox. Depth ( I Eastern Surface Seal Installed by - Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 DepthFiller Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.l 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. ❑ Method of Disposal .. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines x Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS L1 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, 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 performarice of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ` The applic t t call for all require nspections. mplete drawing on fev rse side. i Signed X Title: r Date: 12�6 FOR DEPARTMENT USE ONLY yy E O8 Area 0 Application Accepted by . Date Pit a ro Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 M&Iracy 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. a INFO SCA —��y,�7` J� 190 I + EH 13-24(REV.it Hsi / }"'""` .~- .D�,...... ' � r 3 36+ �4 0 EM 14-26 L..J