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APPLICATiOE1 FOR PERMIT Q * SAN JOAQUIN LOCAL HEALTH DISTRICT VA i� Qom'I 1601 E. HAZELTi 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 E II Local Health District. Il Job Address - �� City Lot Size PM Owner's Name 1 �i/.h fay t.� 9a Y reW Address _ Phone Contractor's Name A C- License No. � Phone TYPE OF WELL/PUMP: ; NEW WELL ❑' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca 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 ❑ Irrigation ---Approx. Depth ❑ Eastern Surfage Seal Installed by Repair Work Done Type of Pumper H.P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing Mate►ia (top 50') Depth Filler Material {Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION El DESTRUCTION ❑ ;No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of 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 s 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'. , l ;,-, i,, Home owner or licensed adepts signature,certifies the following: ';,)-certify that in the performance of the work for which this-permit is issued, I shall not f F employ any penton in such manner as to 4ecome-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 thie Wolk for which this permit is issued,I shall employ parsons subject to workman's compensa- tianlaws of-California." " The app' mu call for all re d inspe ons. C plate drawing verse side. Signed Title: _7 • S Date: r OR,DEPARTME T USE ONLY Application Accepted by - - Date `� 7 re _ y a. Pit or.Grout Inspection y. r Date _ Final Inspection by Dat i s:a 1AV11 Y. . G Additional Comments: 4 — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH +EH 1324(REV.101831 /I 5/1 �,7 �'7— eH 1¢2s S m o 1 �