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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ✓ 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) � .,'4�2() PERMIT EXPIRES TYEAR FROM DATE ISSUED ,tj, _ (Complete in Triplicate) Application is hete6y made to the SJoaquin 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. Jab Address City �7 Lot Size ��y PM Owner's Name d Address _90i 19OX Ph one Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION r AGRICULTURE WELL OTHER WELL PETS/SUMPS _ INTENDED USE. TYPE OF WELL PROBLEM A ONSTRUCTION SPE ❑ Industrial _ ❑ Open Bottom ❑ Manteca Dia. xcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications FI Public f7 Other elta Depth of Grout Seal Type of Grout _ I I Irrigation _._Ap epth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ e of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRYADDITION i I DESTRUCTION 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 A LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMP.,S__.. _ ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will he 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 i certifies the following: "I certify that in the performance of the work for which this permit is issued,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 shall employ persons subject to workman's compens tion Maws of California." The applicantrwst call i all re d inspections. Complete drawing on reverse side. xSigned X Title: ,, Pate: _- 1—=kI FOR DEPARTMENT USE ONLY Application Accepted by Date ZSV_Z" I Area r� i Pit or GFoui Inspection by Date final Inspec'on by Dat Additional 2 Additional Comments: /�� ❑ Stk 466-8781 El Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMI'r'NO. ♦ EH 13-24(REv,i i n 51