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L vif, APPLICATION FOR PERMIT t ry SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE_ STOCKTON, CA l Telephone {2091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIROMENTAL HEALTH I (Complete in Triplicate) FERMIT/SERVICES 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 F 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 Job Address City Lot Size PM Owner's Name / ress IT D W4A Phone Contractor Address Livens No. Phen TYPE OF WELL/PUMP: N'EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 6' 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications *"Public D Other ❑ Delta Depth of Grout Seal Type of Grout _. Q I I Irrigation --Approx. Dh',.,I'«�3 Eastern Surface Sea! Installed by Repair Work Done ED Type of Pump �, c�llt/CL H.P. ��., State Work Do Well Destruction ❑ Well Diameter y Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION l I INo septic system permitted if public sewer is t available 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal k 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 I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a....F 0-hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws ander r 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 sr all required inspections. Complete drawing on reverse side. Signed X Title: _ ��tJ1 , Date:(V """RC1 FOR DEPARTMENT USE ONLY —_2l ff Application Accepted by U __ Date " Area 1W Pit or Grout Inspection by Date Final Inspection by r c ' Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO �AjMOUNT DUE /AMOUNT REMITTED CASH RECEIVED 9Y DATE /// PERMIT'NO., + EH 13-24(REV.1/N 51 /� { r\ "4/ EH 11-28 c/ 1J' l LD o i