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•7�-f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Es 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 N Q`rJ sov�4ni� 6-r— PERMIT EXPIRES TYEAR FROM DATE ISSUED ✓Y� (Complete In Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiUS&n scribed. T +s application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. 1•� Job Address �� 7 ��jCity Lot Size �U X l QPM Owner's Name 'i/ ` - -- Address Z. Phone Contractor Address 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 FLD. PROP. LINE + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications l'1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I 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 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I INo septic system permitted if public sewer is 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest; , Well Foundation Property Line LEACHING LINE Cl, No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS {'l Depth Size Number SUMPS Ll Distance to 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 owrier 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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must�qpit for aIt required inspections. Complete drawing on reverse side. IL Signed J Signed X � Title: _ �..�� _� Date: _ T �a R D XARTMENT USE ONLY r Application Accepted by ed�' •"`' �•_•••�•6t -_________- Date +'� Area I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: —s� ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823.7104 L1 Tracy 1335- 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,tic., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CSR RECEIVED BY DATE PERM17'NO. + EH -24{REV.r/n 51 14 - n Ii►� / y, EH t4�2B V