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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �4"" 1601 E. HAZEL T ON AVE., STOCKTON, CA cad t Telephone {209} 466-6781 w` PERMIT EXPIRES TYEAR FROM DATE ISSUED r : :55 O (Complete in Triplicate) rf0�ritd4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work cribed,,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 Lo�f`the San Joaquin Local Health District. � , f - Job Address `r" ' �""'"r '" City V-� v Lot Size PM Owner's Name —'c r Address - Phone Contract �— License NoA( _�Z`Phone '�/' TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT [I DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ° OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications rX Public F1 Other F1 Delta Depth of Grout Sea] Type of Grout I 1 Irrigation .Approx. Depth l l Eastern Surface Seal Installed by r - c�J\ Repair Work Done A Type of Pump H.P.-3 State Work D e '. Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material IBelow 50'1 �— 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.) Installation will serve: Residence`,I 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 Oistance to nearest: Well Foundation Property line LEACHING LINE ❑ No. & Length of lines Total length/size V' FILTER BED ❑ Distance tonearest: Well Foundation Property Line. SEEPAGE PITS I Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line >ti _ r 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, anck rules and regulations of the San Joaquih-L-ocal-Health Di'frict. Home owner or licensed agent's signature certifies the fallowing:,'l certify-that,in the performance'ot the work-for-which this permit is issued, I shall not employ any person in such manner as to becomi subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature i ... : certifies the following:"I certify th'a in the performance of thea workfor'which-this-permit-is-issued-lshallBmplay_persons subject to workmans compensa- tion laws of California." The applicant must call for all regr{i 9d ins ctions. Complete drawing on reverse side>, . Signed X f Title: d1 Date: FOR DEPARTMENT USE ONLY Application Accepted by / Date 5� Area / Pit or Grout Inspection by Date Final Inspection by - Af 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 y`4, FEE AMOUNT DUE t AMOUNT REMITTED CK' RECEIVED BY DATE PERMIT'NO. i INFO CASH +.EH 1324 IREV.t/H 57 �l3 EH U-28 -_