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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.619 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. M„. vo ��/ +r rt L✓P 1 -�U N L w --�— Lot Size— PM Job Address Ci „ - - Owner's Name f A•l Address • -- Phone f . Contractor' Address License No.'De�Phone TYPE;OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ �. jPUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ it DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE fr + : FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r (-i Domestic/Private ❑ Gravel Pack EI Tracy Type qT Casing SpeciRcations ❑ Public ❑ Other ❑ Delta Depth of Grout Seal + Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ` H.P. 'State Work Done r C Repair Work Done ❑ Type of Pump I Well destruction ❑ Well Diameter - Sealing Material (top 509 C I Depth Filler Material(Below 50') `- ;' TYPEAF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION V7DESTRUCTION ❑ (No septic system permitted if public sewer e r• available within 200 feet.) Commercial Installation will serve: Residence 1-1 —•�'Other _ ^ ( Number of Irving units: Numberfof bedrooms _ t Character of soil to a-depth of 3 feet: �'.!Zrc Writer table depth— { SEPTIC TANK ❑ Type/Mfg Capacity ' No.,Comparurenn t PKG. TREATMENT PLT.❑ I � ;s - Method of Oispoeal Dbmnct;m n_ y' aff let: e11' Foundedon` Property Line! ' LEACHING LINE VNo. 8 Length of lines I Z I($ Total length/size ' FILTER BED ❑ Distance to nearest: i Well. Foundation Property Line i r SEEPAGE PITS ❑ Depth _' " Rue! erty Number + ' . SUMPS ❑ Distance neareat�Well+ Fouitdetion PropLire I _ r DISPOSAL PONDS ❑ I �_•' I hereby certify that I have prepared this application and that the work will be dare in accordance with-Son Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. c 1 "1 certify that in 1h0 pgr(orrtmnce of the work for which this Permit is issued, 1 shall not Horne owner or licensed agent's signature certifies the following: employ any person In such manner as to become subject to workman's compensation.laws of California.;' Contractors hiring or sub-wttracting signature cart'dies the fosowing: "1 certify that in the performance of the work foryohich this permit is issued, I shall employ persons sublact to workmans compensa- tion laws of California." .. t The applicant must call for all required inspections. Complete drawing on reverse side. Signed x_'Y^•,b'w�='-I�fAtz✓ + Title:�,� "f�' r Date? ( FOR DEPARTMENT USE ONLY Application A'ccept�tRJ "~ �I^r� Date Area _ . .� Pit or Grout Inspection by+ _ - _ —' -Daft Final Irapectlon by Additional Comments: i' ❑ Stk: 466-6781 ❑ Lodi 369-3821 ❑ Manteca 873.7104 ❑)racy82154M8 Applicant - Return all copies to: Environmental Health Permit/Services 1001 E. Hazelton Ave, P.O. Box-26D9, Stk., CA 95201 f + •' FEE AMOUNT DUE ` AMOUNT REMITTED -CK ,r.•' I IiCENED BY +a DATE PERMfT NO.f INFO CASH.--- • F--. _L �7 P '. ♦ til IM6 IRW.+i a sl 7C> •moo 'a`-Y$ I'� EN r&"' l -