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APPLICATION.FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2 09) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . r z: (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 Local Health District. "'"' ' u I �,/(� ,,. ,� ,� , ;.� , �. X 1a Job Address �T �' `�- -- "` ./_ !"i r1/ r, City 17411-7 Lot Sizex� ,_ ,.. . PM Owner's Name� �r _f 1r Address l� -3 , e �/9!° ~p hone 7 Contractor Ute' ! e/L 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 # FOUNDAT AGRICULTURE WELL OTHER WELL, -- � PITSI /SUMPS.' INTENDED USE TYPE OF WELL M AREA CONSTRUCTIONS CATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of xcavation Dia. of'Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grp al Type of Grout ❑ Irrigation �pprox. Depth astern Surface Seal.Installe y �M Repair Work Done ❑ Type of Pu H.P. State Work Done Well Destruction ❑ Well meter Sealing Material Stop 50'1 -- � i Depth _ Filler,Material (Below 50') s. TYPE OF SEPTIC WORK:_ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septicesysterri,permitted if public sewer is s 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 l:.. Water table depth SEPTIC TANK ❑ Type/Mfgr I Capacity No. Compartment� r� PKG. TREATMENT PLT. ❑ ..Y Method of Disposal O Distance to nearest: Well Foundation Property Line A LEACHING LINE ❑ e No. & Length of lines r Total length/size t t i FILTER BED ❑'--Distance-to a est: Will Foundation Property Line _ SEEPAGE PITS ❑ Depth Size a Number I! / SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ „ q 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. W 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 4 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature- t 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 applicarleoust call for all required inspections. Complete drawing on reverse side. llrt Signed XEW Title: ., r S r- - Oate: FOR DEPARTMENT USE ONLYIi Application Accepted by Date _2_� r :Area �I� _ Pit or Grout Inspection y Date Final Inspection by Dat Additional Comments: �'�"" 2»L4L? k� t� IIi ❑ Stk 466-6787 ❑ Lodi 369-3621 M Manteca 3-7104. ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health P mit/Services 1601:E. Hazelton Ave., P.O. Box k.; CA 9P201 I� FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. NFO I + EH 1 -241REV4 EH 14-28 'T