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APPLICATION'FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT c�opV 1601:E. HAZEL.TON AVE., STOCKTON, CA Telephone (2091466-6781 I 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' 7 City Job Address 41 N + Owner's Name - ,_ Address Phone . ' �� j `1 Address ' ^' license No. Phone Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 13DESTRUCTIO PUMP INSTALLATION'❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLO. 60 — PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS [, I, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial EIOpen bottom ❑ Manteca Dia. of Well Excavation Dia- of Wall Casing 3 Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack O Tracy YP 9 i [7_Public Cl Other ( n Delta Depth of Grout Seal Type of Grout k I 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by ! H.F- State Work Done Repair Work Done ❑ Type of Pump ' Well Destruction CK Well Diameter Sealing Material [top 50') Depth I Filler Material IBGlow 50'1 *A' TYPE OF SEPTIC WORK: NEW INSTALLATION ILI REPAIR/ADDITION t-1 DESTRUCTION I I INoave septic system permitted it public sewer is ^ available within 200 feet.) � Installation will serve: Residence-4- Commercial— Other ;. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet•. - Water table depth I SEPTIC TANK ❑ TypelMfg Capacity No. Compartments PKG, TREATMENT PLT.a Method of Disposal, Distance to nearest: Wall Foundation Property Line I l � I LEACHING LINE ❑ No.&Length of lines Total.length/sit e FILTER BED ❑ Distance to nearest: , Well Foundation Property Line r SEEPAGE PITS I I Depth ; Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 111 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 Joequin 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 P workman's compensa- tion terrifies the following; "I certify that in'the performance of the work for Which this permit is issued,i chalk employ persons subject to wo pe tion laws of California." I The ap licant must c or t r red inspections. Complete drawing on reverse e. I Signed - Title: Date: 1a t FOR DEPARTMENT USE ONLY ' y Application Accepted by �! --Date Area Pit or Wut Inspection by Date Final Inspection b Date Pe (171 Addi tonal CommeA[s r ❑ Stk 466-6781 E) Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 8311-5385 Applicant- Return all coples to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.P. Box Stk., CA 95201 ,,11 .�' r I- .1- µ<<f/ wut cCts d iti l9fig• �.c�cef rr14 a�efd c„r�J-� FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVE)BY DATE PERM11'NO. INFO EH 13.21(REV.t i n si ` � G �.- f 'f EH 14.28 ✓✓✓ '