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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 (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 Health District. � �! I u�¢.�T Job Address city �''� Lot Size � �� PM Rlr�,�o IYl,Aiel Address / S ��•'a4iPhone �1 � Owner's Name _ ' Contractor' / � .Cvr.- Address s u�o, f License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE w,TYPE OF WELL -PROBLEM AREA F"CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 111Manteca } Dia. of Well Excavation ` Dia. of Well Casing El Domestic/Private ` 4❑_Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public El Other, 4 _ElDelta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ' H.P. State Work Done Well Destruction ❑ Well Diameter"" Sealing Material atop 501 F Depth Filler Material i8elow 50'1 LV J7 available TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIRlADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is r 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: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ r _ Method Df Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance.to nearest: well. Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." { The applicant must call for all required inspections. Complete drawing on reverse side. Sig nad Title: Date: 2:== Y Application Accepted by 0" Date '3—)e3—q_7 — Area t/ r Pit or Grout Inspection by Date Final Inspecti by Date/, Additional Comments: /f ( JT lin ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 1/� Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r" ' /91 � d QK-03 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'N0. � INFO + EH 1 -24 iREV.ti/8 51 �5�. - + EH 144-28 l