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APPLICATION FOR PERMIT rr i SAN JOAQUIN LOCAL HEALTH DISTRICT G� f ; `! 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 !j PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) !a 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 :1 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 I Local Health District. I Job Address_3.2! City Lot Size PM I Owner's Name Address y f+P _ _ P4 _ F,2 Z I r �Contracto Address �(a �I��Ci1 License N e- Phop� j:TYPE OF WELL/PUMP: # NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ !1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �TDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA PROP. LINE i FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS i1 INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTlON SPECIFICATIONS I I ❑ Industrial ❑ Open Bottom ❑ Man Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑/Gravel Pack Tracy Type of Casing Specifications E1 f 1 Public 171 Other - C 1 Delta Depth of Grout Seal Type of Grout i I # Irrigation h A iI J Approx. Depth I I Eastern Surface Seal Installed by iRepair Work Don Type of Pump H.P. State Work Done Well D tion ❑ Well Diameter Sealing Material atop 501 . t Oepth Filler Material (Below 50 v hTYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i i. DESTRUCTIONfNo Septic system permitted if public.sewer is e I� vailable within 200 feet.) Installation will serve: Residence_ Commercial— Other" i Number of living units: Number of bedrooms Character of soil to a depth;l of 3'feet: _,- Water table depth i SEPTIC TANK ❑ I Type/Mfg Capacity No. Compartments ,i,PKG. TREATMENT PLT. ❑ y� Method of Disposal lDistance to nearest: Well Foundation Property Line i�' I; E LEACHING LINE ❑ o. &.Length of lines Tocol length/size i is FILTER BED ❑ ;Distance to nearest. Well Foundation Property Line 4. IS SEEPAGE PITS I I .��Depth Size Number r !.SUMPS ❑ i Distance to nearest: Well Foundation Property Line ?DISPOSAL'PONDS ❑ id 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. 3 Home owner or licensed agent's signature certifies the following: 1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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- 4 r 'tion laws of California." r I� gThe applicant ust call for all required inspections. Complete drawing on erse slid pr^7 IlSigned X Titfea �� Date: 7— y I. FOR DEPARTMENT USE ONLY Application Accepted by _Date Date — — ea O Pit or Grout Inspection by 'I DateFinal Inspection by Date `Additional Comments: I 3 10 Stk 466-6781 ❑ Lodi 3691 0 Manteca 823-7104 ❑ Tracy 835-6385 F :Applicant - Return allcopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 21)09, Stk., CA 95201FEE ' INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT"NO. ! . t3-2�(REV.r i e, EH i4-2e .i F