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r APPLICATION FOR PERMIT 41f A\O SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (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 i Local Health District. Job Address .L q()ij ' City Lot Size PM ��J /�5 p Owner's Name 1/ ��-• Address Phone r +I Contractor_ s �_ _ SSS }�_��+ '� .License Nv. r. �l�JPhone I TYPE OF WELL/PUMP: Y NEW WELL ❑ WELL REPLACEMENT.❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom © Manteca —.Dia-of-Well-Excavation— -----= Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications r i"1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation —..Approx. Depth l l Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of-Pump H.P t State Work Done T Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [:I ,REPAIRIADhTION OESTHUCTIg4 l I I septic system permitted if public sewer is I ikable within 200 feet.] Installation will serve:aResidence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ater table depth SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments-- PKG. TREATMENT PLT. ❑ #! Method of Disposal Distance to-nearest: Well Foundation Property Line r O k LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED I❑ Distance to nearest: Well Foundation Property Line f r - _ r SEEPAGE PITS l 1 Depth Size Number L SUMPS 0 Distance to nearest: WellFoundation `" Property Line Vn 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. . F 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 .d 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: "t 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." r L The applicant/gust call fo required ' spections. Complete drawing on reverse side. �- r Signed X Title: ��[��(..,�, Date: £ FOR DEPARTMENT USE ONLY 1 Application Accepted by Date ft 1I r Area I E � Pit or Grout Inspection by Date Final Inspection bDate 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 Ava., P.O. Box 2009, Stk., CA 95203 a FEE—-.AMOUNT DUE,: —AMOUNT-REMITTED— CK RECEIVED-BY.- —DATE= t PERMIT'No. INFO CASH'°°"' ' a I + EH 13-24(REV.I/H f EH 1426 , 1