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r r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r v . (Complete in Triplicate) t 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 JoaquinCounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and'Regulations of the San Joaquin Local Health District: : 1 Job Address F► r '��+r� � City Lot Size PM - it Owner's Nam Ve, I r ` Address _ - !tel �r Phone Contractor� -ryFj Address- - __.. -. �- License No._' Phone—_ - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 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 IJOpen Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy., ' :„Type of Casing Specifications ❑ Public ❑ Other ) ❑ Delta Depth of Grout Seal Type of Grout EJ irrigation { _—Approx. Depth ❑ Eastern Surface Seal Installed by -� [ Repair Work Done ❑ Type of Pump H.P. State Wnrk Done r Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) r installation will serve: Residence c I Commercial, Other._, Number of living units: Number of bedrooms -3 Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK . ❑ Type7Mfg apacity_ (� No. Compartments PKG. TREATMENT PLT. ❑ i, � Method of Disposal`f C Distance to nearest: Well Foundation, Property Line Total len th/size LEACHING LINE 171 No. &Length of lines 9 FILTER BED ❑ Distance to nearest: Well Foundation Property Line j SEEPAGE PITS C] Depth Size I71 Number SUMPS ❑--Disfance to nearest:' 'Well Foundation Property Line DISPOSAL PONDS ❑ I.hereby certify that I have preparedlthisrapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Aaquhr Local Health District. f 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-becomwsubject to workman's-compensation laws of California.”Contractor's hiring or sub-contracting signature kcertifies 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 required inspections. Complete drawing on reverse side. Signed Title: r►'at� f Date: , V�_.. FOR DEPARTMENT USE ONLY L� Application Accepted by �J Date r Area D� E. Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: : Y t] 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 45201 4 ysf � ♦ __r r � FEE AMOUNT bUE t AMOUNT REMITTED CASH RECEIVED_BY1 DATE PERMIT''NO. INFO - +EH 1324{REV.1/e 5) —7D i EH 1426 I -