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APPLiCATION-FOR PERMIT ' SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,;STOCKTON, CA Telephone (209) 466-6781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED... (Complete in Triplicate}. :. n I 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.54.9 for sewage:_or_No. 1862 for well/pump and the Rules and Regulations of the San Joaquin 1 Local Health District. Job Address / .City _5-70CAV* Size PM Owner's Name l�I�' �t�i�1'/f' 'Address /- C Phone s � Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �` PUMP INSTALLATION ❑ SYST REPAIR ❑ OTHER ❑ DISTANCE TO NEAR ESTi`SEPTIG TANK-,. _ SEWER LINES DISPOSAL FLD. - —PROP.-LiNE- FOUNDATION __. A RI6ULTURE ELL•-k --- OTHER-WELL I —,-PITS'/SUMPS iNTENDED USE TYPE OF WELL PROBLEM A A C NSTRUCTION SPECIFICATIONS T � t❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation _ Dia. of Well Casing I� ❑ Domestic/Private ❑ Gravel Pack a ❑ Tracy of Casing Specifications' i ❑ Public © Other �❑ Delta '�' Depth Grout Seal Type of Grout k : ❑ Irrigation t, _ _.Approx. Depth ❑ Eastern Surface Se Installed by �• 1 Repair Work Done ❑ Type of Pump H. P. State WorkDone Well Destruction ❑ Well Diameter j Sealing Material {top 501 Depth p Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.I ; Installation will serve: Residence_ Commercial— Other f 3 Number of.living units: Number of bedrooms Character of sail to a depth of 3 feet: I =r Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity }; No. Compartments PKG. TREATMENT PLT. ❑' C, €Method of Disposal Distance to nearest: Well Foundatiore Property Line LEACHING LINE ❑Y No. & Length of lines Total length/size FILTER BED1 ❑ Distance to nearest:--Well - Foundation Property Line r SEEPAGE PITS ❑ Depth Size Number I SUMPS i ❑—Distance to nearest: . WellFoundation 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, I shall not 1 employ any person in such manner as to become:subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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." - - �•._ A The applicant must call for all required inspections. Complete drawing on reverse side. Signed X i e Title: _ a Date: f FOR DEPARTMENT USE ONLY r Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b Dat 2r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369 3F1 ❑ Manteca -7104 . ❑ Tracy 183A3ffi Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O- Bax 2009, Stk., CA 95201 I r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. t INFO +'EH13-241REV.tiaSt _qq EH 14-29 �•!-..•! 4� �/