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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 9 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. i Job AddressgZW) d� City Lot Size PM Owner's Name (zu Addres1 ozr? r Phone ContractusVZ, 11r+ � earess �/ (i1/�/�i1 /<L/ License fro. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �OA�YSTEM REPAIR ❑ i OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ! Dia. of Well Casing F ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t I Specifications I F1 Public Ll Other /? 1`tl Delta Depth of Grout Seat Type of Grout I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _. . Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') 1 I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is t available within 200 feet.) �\ y, ! Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: T `gVllater table depth SEPTIC TANK ❑ Type/Mfg \ Capacity ��SNo. Compartments PKG. TREATMENT PLT. ❑ rf.tjP ,t Method of Disposal Distance to nearest: Well Fo ndation r Property Line LEACHING LINE ❑ No. & Length of lines V_ I Total length/size I FILTER BED L1 Distance to nearest: Well Foundation E Property Line SEEPAGE PITS t I Depth Size Number 1 SUMPS 11 Distancelto n'eear�st: ;Wel Foundation Property Line DISPOSAL PONDS ❑ �ti�T ye `j E i I hereby certify that I have prepare tFiis application and-thattf�e work will be done in accordance with San Joaquin county ordinances, state laws, an .i rules and regulations of the San Johquin Local Health District. Home owner or licensed agent's sig6ature certifies the following: "I certify that in the performance of the work'for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California." Contr'actor's hiring or sub-contracting signature certifies the following: "I certify that n the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." _ I AP k The applicant st v`eq r— . Complete drawingon re side. i Signed X Titl i Date: DEPARTMENT USENLY Application Accepted by Datey �" }� Area Pit or Grout Inspection by Date Final Inspection , Date (� r Additional Comments: 0 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 95241 t INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEFVED BY DATE PERMIT NO. + EH 1 -241AEV EH 144-28 .r/M 51 *3S x-14-y —1yy I