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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CAf Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) �` 1 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. iQk Job Address !t '!� 14 1 �" �C� City Lot Size PM Owner's Name RO,K [dress �� f Phone Contracto r Address — License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industfial ❑ Open Bottom If Manteca Dia. of Well Excavation Dia. of Well Casing `' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public (7 Other ❑ Delta Depth of Grout Seal Type of Grout � . E Irrigation —_Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I ) H[PAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is 1 available within 200 feet.) 'Installation_will serve: Residence +' Commercial Other ` Number of IivingriRss` _._. Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK M � 111p Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal i 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 r\ SEEPAGE PITS� "'lil Depth s_-'.• ,i Size_ Number SUMPS LI 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 L'ocal,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 inanner 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,1 shall employ persons subject to workman's compensa- tion laws of California." n The applicant,must call for all requir' inspections. Complete drawing on reverse side.. S117 igned X Title: �� `fJ�.( �`�--' Date: �/ �. J"�`.-,�. � r._�-.�';,) ,ate � j \. FOR DEPARTMENT USE ONLY ir Application Accepted by _-- .- Date Area Pit or Grout Inspection by �{�j Date Final Inspection by Date "�i Additional Comments: � — fJ!` j v ❑ Stk 466-6781 ❑ Lodi 369-3621 EAManteca 823-7104 D Tracy 65-13N5 . Environmental Health Per 'Services 1601E Hazelton Applicant - Return all copies tnAve., O�Bex-28g,9- •�rn nc�ry� ..,_.•-�'_. -^„ � e Mr � -..� `*`��1.rte_.,— r --{ay,.a--� _ -�._.� � E` .6 FEE INFO AMOUNT DUE _ AMOUNT REMITTED CK RECEIVED CASH BY _DATE RMIT N0. x ♦.EH13.244REY.i/n5) EH t4-2s S a 4