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w: APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,ION AVE..; STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . " t (Complete in Triplicate) 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 H"Ith District. ;; I t , = /2��y City Lot Size ` PMS Job Address, — °, Owner's NAddress -� Phone � O ame Contractor ss� License No. hone TYPE OF W LL/P P: NEW WELL ❑ t WELL REPLACEMENT ❑ DESTRUCTIONCI ' PUMP INSTALLATION ❑ �` `, SYSTEM REPAIR ❑ i 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑.Other I ❑ Jetta Depth of Grout Seal Type of Grout ' ❑ Irrigation L_41plrox. Depth F1a Estern Surface Seal Installed by I Repair Work Done 11Type of Pump H.P. State Work Done a+ Well Destruction ❑ Well Diameter ' Sealing Material (top 501 3 - t r -"-- Depth ' Filler Material iBelow 'I I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceCommerciai_ 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. ❑ �� I Method of Dfs osaf t Distance`to"nearesti': Well Foundation�� Property Line LEACHING LINE ❑ No. & Length of lines --- Total length/size FILTER BED ❑ Distance to nearest: Well/047 47 O'undation Property Line SEEPAGE PITS ❑ Depth Size f Number SUMPS ❑ Distance to nearest: Well FoundationProperty Line .__.— DISPOSAL PONDS F7 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, I shall not i 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." t� The applicant Must cal.14or al equire ctions. Co plet drawing on-Dworse side. Title: /�/1/ Signed - Dat ,. - r FOR DEPARTMENT USE ONLY l.� t Application Accepted by _ Date $h Area 4 Pit or Grout Inspection by Date Final Inspection b Date �ddltional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Alilplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT ND. INFO !! CASH �] 1 ^► ^7 + EH 13-24(REV.s/e 51 i ( I { 1 i 27 EH 14-28 V