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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED w r (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. �/d p� � ,�y eu t["4r Rb Jab Address 1�t 0�,say-/s- City Lot Size PM ��/G1>2rJ 'c��.��it5 Z K4E7r?1 l r Phone Owner's Name Address i Contractor ��n � ��jti e-o Address 360 4 € License No.,,SCYS 3 Phone Aq 7 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 F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x— r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing �WDomestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications l'1 Public 1-1Other ❑ Delta Depth of Grout Seal Type of Grout W ' I I Irrigation —.Approx. Depth• I i Eastern Su face Seal Installed by - 5`[ H.P. f State Work Done �/S Repair Work ❑ Type,of Pump _ WellDestruction ❑ Well Diameter� XSealing Material Itop 50'1 Depth s• -Filler Material (Below 5012`JDi TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l 1 (No-septic system permitted if public sewer is available Within 200 fe6i') � Installation will serve: Residence_ Commercial--Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity 1`No. Compartments PKG, TREATMENT PLT. ❑ r., Method of Disposal AI Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size ..� FILTER BED O Distance to nearest: Well Foundation Property Line j • t I SEEPAGE PITS I l Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line L 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. i 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 " i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature a 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." ql The applicant must call for all required inspections. Complete drawing on reverse side. J r �? Signed X Title: / ��5 Date: DEP ENT USE ONLY Lr } Application Accepted by Date � A� Are [ z i 1 !� ` Date --� Pit or Grout Inspection by Date Final Inspection by Additional Comments: +�� ! + ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca' 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environ^ ntaI Health Permit/Services 1601 E. Ha rlton Ave., P.Q. Box 2009, §tk. 9 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASHEN �/� EH 13- �F '{ 24IREV.i/H51 �! 9q a _ �� i/*01—_