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APPLICATION FOR PERMIT 1' I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA .z Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SES 1 � � (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby matte to the San Joaquin Local Health District for a permit to construct and/or install th�vt+drk'Y 'r�ih dBsiMF. s 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. f � City Lot Size PM Job Address L Address t Phone J (3 U Owner's Name a ` -` � I �1 L License No.� ► Phone 1 f Contractor Address TYPE OF WELL/PUMP: NEW WELL F] WELL`REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK 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 Weil Excavation Dia. of Well Casing XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casing - Specifications F f'I Public f-1 Other "" 17 i Delta Depth of Grout Seal--':--e Type of Grout I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump 1 SUS H.P �� -----State-Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) fL L 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 SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT-PLT. ❑ l Method of Disposal Distance to nearest: Well Foundation Property Line ` m � LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED ❑ Distance to nearest: Well �r Foundation T Property Line SEEPAGE PITS I i Depth Size Number SUMPS Ll Distance to I 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, l shall not employ any perso in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fall in : "I certify"that in the performance of the work for which this permit isr issued, I shall employ persons subject to workman's compensa- tion laws of C ifo Ia.- app _. { The li nt u call for all re ui ed inspec r ns. C plate drawing on rave se side. Signed X Title: - Date: FOR DEPARTMENT USE ONLY v �, I Application Accepted by f Date / Area Pit or Grout Inspection by Data Final Inspection by ✓ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 -Applicant"-Return,all--copies to:-Envirohmental Health Permit/Services 1601 E. Waielton Ave.,P.O. Box 2009;'Stk., GA 95201 CK# FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO /!) `y ♦.EH13-24EREV.iiH51 �' _ /t.-1f[�'D... �O 4 17 - f