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APPLICATION FOR PERMIT `f- 3 r SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is heieby 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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health Districts f� j . Job Addresslo—' " s�. �!C�C-�J City Lot Size PM Owner's Name `i' L� Address�� ! "/U �'yi u� Phone F21-20 �O Contractor ".1`"__Address�P 7 �' —" "�`� License Noll�3 1 Ph,, �n TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL S OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q`Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public W CI Other Cl Delta Depth of Grout Seat Type of Grout _ I I Irrigation --Approx. Deph l 1 Eastern Surface Seal Installed by _ I Repair Work Done R- Type of Pump H.P. r State Work Done Well Destruction ❑ Weil Diameter ' Sealing Material (top 50') Depth I Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I], REPAIR/ADDITION E I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) I T Installation will serve: Residence_ Commercial _ Other Nuinber of living units: -�Numlier of beifrooms Ch racter of soil to-a-depth-of-3`feet: ` `�� SEPTIC TANK EIType/Mfg Capacity f No. Ca a ;- PKG. TREATMENT PLT. ❑ f C Method,_ Disposal - - Distance Ito-nearest: Well Foundation Property Line �- "71ggv LEACHING LINE. ❑ No. & Length of lines Total length/size FILTER BED }. .per Distance to nearest: Well Foundation Property LiARQ�rAjALT + �±Ll'LLLIS�i rte/inrn ' SEEPAGE PITS 11 Depth 1 Size Number SUMPS 0 Distance to nearest:. Well Foundation f 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 1 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant r4st cat)for all re red inspections. Complete drawing on reverse side. r ��e L+ �' . Date: Signed X itle: ..,,..,. ' / I * �z FOR DEPARTMENT USE ONLY �. Application Accepted by i' Date Area Pit or Grout Inspection by F Date Final Inspection by tate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 x FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO { CASH +.EH 13.24 1 REV.i/a 51 EH 11-28 1