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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT P 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED } , (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 t 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 Sart Joaquin ` Local Health District.. r 1 r . 1 Job Address 1-Yi! �t''L City .Lot Size PM Owner's Name .�. 1 Address - Phone Contractor's Name License No. r r D � — Phone + TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION �r SYSTEM REPAIR IN OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL .. PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y �t r.. 'O Industrial ❑ Open Bottom=r ❑ Manteca Dia. of INeII Excavation "" Doa. of Well Casing El Domestic/Private L1 Gravel Pack A ❑ Tracy s Type of Casing Specifcations L. ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout rax. Depth - ❑Eastern- L. —Surface Seal Installed by - - ' . ❑ Irrigation —app f . Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth i It / Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is ` i r available within 200 feet.) 3r Installation will serve: Residence_ Commercial_° -Other units: Number of living Number of bedrooms Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg , Capacity No. Compartments PKG. TREATMENT PLT. ❑ I t -=� Method of Disposal z Distance to nearestr---,Well t Foundation Property Line t' LEACHING LINE ❑ No. & 1_6gth of lines Total length/size FILTER BED l Distance E to nearest: Well Foundation Property Line a. I f SEEPAGE PITS ❑ Depjt�_I . Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ * I hereby certify that I have prepared.xhis 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 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 inthe performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa tion laws of California." The applican of c I for al a 'rey inspections, Complete drawing on verse si L Signed Title: ` r.�a+11 Date: A FOR DEPARTMENT USE ONLY Application Accepted by ti- ' 'ON Date 2� Area Ags t { Pit or Grout Inspection by Date Fina! Inspection byf,7.. Date Additional Comments: r ° �Stk 466$781 ❑ Lodi 369-3621 11 Manteca 823-7104 ❑ Tracy 835 6385 Aplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO.' INFO +,EW 13-24(REV.10!931 EH 14-28 - - L.