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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT S' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereind e . This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .� 7 7 O /' - _ �— City Lot Size PM r Owner's Name _ �L� _ Address Phone Contractor &44_ Address es License No.el t `1® Phone l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WEL S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT CIFICATIONS \ ❑ Industrial ❑ Open Bottom ❑ Manteca . O Well Excavation Dia.-of Well Casing Ilk ❑ Domestic/Private ❑ Grave�Packo Type of Casing Specifications F Public f! Other Depth of Grout Seal ' Type of Grout 1 1 Irrigation ? prox. Depth l I Eastern,. Surface Seal Installed by - t. Repair Work Done ❑ 7 pe of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material stop 501 Depth Filler Material (Below 501 # TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTIO INo septic system permitted if public sewer is vailabie within 200.feet.) Installation will serve: Residence_- Commercial— Other Number of living units: - Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.4ThATMENT PLT. ❑ t rF Method of Disposal v `1k Distance to nearest: Well Foundation Property Line yv r LEACHING LINE-" ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation " Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 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." /` s The applicant ust tali for all require inspections. Complete drawing on reverse side. /� Signed X Title: , Dater Y R TMENT USE ONLY Application Accepted hy, _(��awn ,.._ _ Date 3 Area Pit or Grout Inspection by Datte, F / �yFinal inspection by' Dat Additional Comments: - � � -'' rv�'' z U ✓ 0 �' / 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca:.82377104 ❑ Tracy 835-6385 Pih.U V i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INF Q AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. �.EH 13-24 1REV.1/H 51 -0 a 3r5 ��3 4 y'I`� 01 L r EH 14-26. - t