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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 - . :_ { PERMIT EXPIRES 114YEARFROM 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. Job Address . s K t 1 f ?13 0_'e_ City Lot Size PM Owner's Namr # tQ Address � _ /} 1 1 f 1��iU t/1 Phone Contractor L. _�- Address 19 b 't License No.3 3 3 1 Phone +� TYPE OF WELL/PUMP: _ NEW WELL ❑„ WELL REPLACEMENT ❑ DESTRUCTION 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '% DISPOSAL FLD. PROP_,_LINE FOUNDATION AGRICULTURE WELL tE OTHER WELL " � PITS/SUMPS INTENDED USE_A TYPE OF WELL PROBLEM AREA-.,.•COINSTRUCTION SPECIFICATIONS ❑Industrial ❑ Open Bottom ❑ Manteca' Dia of Well Excavation Dia. of Well Casing • ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications f'l Public 1-1 Other I Cl Delta 'T Depth of Grout Seal Type of Grout 11 Irrigation -�prox Depth 1 Eastern Surface-Seal Installed by Repair Work Done ElType of Pump H.P. ' ' -` r State Work Done m Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material !Below 50'1 { TYPE OF SEPTIC WORK: NEW INSTALLATION I 1° REPAIR/ADDITION 1 I DESTRUCTION l fNo septic system permitted if public sewer is 4 # available within 200 feet.) 1 installation will serve: -Residence -A Commercial— Otheryr ' P- r Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: , 1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ti Distance to nearest: Well Foundation Property.Line /) LEACHING LINE ❑ No. & Length of lines Total length/size P FILTER BED ❑ Distance to nearest: Well Foundation Property Line r h} SEEPAGE PITS I I Depth i I Size Number ) r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 i i 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 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,1 shall employ persons subject to workman's compensa-5-_ i tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. 4 Signed X Title: Date: � 9` c I .# �E FOR-DEPARTMENT-USE-ONLY Application Accepted by .bate L- O � '� �- � r Area � `,v . Pit or Grout Inspection by /Date Final In p ctian byDatr�//D 8� k Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED A5R RECEIVED 8Y DATE PERMIT'NO. +.EH -241RE 14 EM -26 it