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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. � r Job Address S9s© ,� y '`Lz " `•Le _ City Lot Size - d PM X72 �. .�, �! i� �a c�1fio J �s Owner's Name �� Address �r - C' /I Phone f N Contract Q Address r•�. License No. r �z�Phone ��'�� V`) 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications _ Y ❑ Public ❑ Other ❑ Delta i Depth of Grout-Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Suiface Seal lnstalled by.'. T Repair Work Done 'D - Type of Pump T H.P. ' * ' Slate Work Done Well Destruction � ' ❑' 'Well Diameter •— Sealing Material(top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR/ DDITION 8- DESTRUCTION ❑ (No septic system permitted if public sewer is 4 _ '(} {� avai#able within 200 feet.) ` Installation will serve: Residence— Commercial_ OtherLjL,_-J A Number of living units: Number of tedrooms i ` L Character of soil to a depth of 3 feet: '+ _ _� ^_"� Water table depth iD SEPTIC TANK r ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation 2y Property Line LEACHING LINE ❑ No. & Length.of lines .Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - Property Line li L t SEEPAGE PITS Q�Depth S`- . Size Number SUMPS ❑ Distance to nearest: .Well (SC FoundationS1 C) _ Property Line_. r 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 orslicensed agent's signature certifies the following: "I/certify that ih-the performance of the work for which this permit is issued, !shall not employ ani/person in such ma`nner'as to become subject to workman's compensation laws;of California."Contractor s hiring or sub contracting signature ' -"certities'the follbv ing.-''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-Iaws;of,Califomia." r TWapplican't ust call ffor[ I re uired inspections. Complete drawing on reverse side. r� Title: - Date: mall 1714-A Signed ; FOR'DEPARTMENT USE ONLY" �.•- ` ,_•., r, bate J Area Application Accepted by J Pit or Grout Inspection by Date Final Inspection by Date Additional Comment ❑ Stk 466-6781.- ❑'Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy '835-6385 �4 Applicant- Return all copies oto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 =r_ ry INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PT}EERMIND. +EH 13-24 UtEv.i/e 5] EH%28