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APPLICATION FOR PERMIT r, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ''� Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED 1 (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. Job Address Cit. Y_e4o �112 Lot Size a PM_ Owner's Name A(M �A6C ✓i Address Phone el Contractor �' Address } r (J License No`s` Phonert- TYPE OF WELL/PUMP: NEW WELL . WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 3 P 0 SEWER LINES DISPOSAL FLD. PROP. LINE,,-n F 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 I >-,/Domestic/Private "' Gravel Pack C1 Tracy Type of Casing Specifications (r F1 Public 1-1 Other 71 Delta Depth of Grout Seal 5 2— Type of Grout I I Irrigation 1)- Approx, Depth I I Eastern Su ace Seal Installed b c?A�, ti I Repair Work Done ❑ Type of Pump -1 H.P. _ - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK:- NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is O i available within 200 feet.) ' Installati ill serve: Residence_ Commercial— Other Number of living um . Number of bedrooms Character of soil to a depth of Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal � Distance to nearest: Well undation Property Line { LEACHING LINE. .. ❑ No. & Length of lines at length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Pro Line SEEPAGE PITS i I Depth Size Number SUMPS L1 Distance to nearest: Well FoundationProperty Line DISPOSAL PONDS ❑ I hereby certify that I have ptepared 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 l 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: "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 applicant must a call for all re fired inspections. Complete drawing on reverse side. _ Signed i_ Title: l' Date: �--- FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by (�!- Date �d Final Inspection by Date2 ' 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 Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUN�IREMITTEM (NFDCASH RECEIVED BY DATE PERMiT'ND. ♦ EH 14-21(REV.t/xs) 4� O T3 �T_ `� I L..� Fs-7-401 f Ek 11-28 l,tJ �