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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT'ON AVE., STOCKTON, CA Telephone (2091466-6781 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. 549 for sewage or No. 1862 for well/ pump and the Rales and Regulations of the San Joaquin Local Health District. 1 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, 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 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." IE The applicant must call for allmquired inspactI Complete drawing on re rse side. Signed Title: Date: a� Application Accepted FOR DEPARTMENT USE ONLY 1 by data /, Area Pith or Grout Inspection by Date Final Inspection b �S Y Date Additional Comments: ? LI Stk 466-6781 ❑ Lodi 389-3821 ❑ Manteca a23-7104 Q Tracy 8354M Applicant - Return all copies to: Environmental Health Pemrit/Services 1801 E. Hazelton Ave., P.O. Bot 2009, Stk., CA 9=1 l FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVBY DATE FERMIT'NO. INFO CASH ED 1 t4.z♦ IREV.1/B51 fro 01 �tlp lr-1Z b� 85-1 83 ..EH 142b L� o • Jo b Address City Lot Size PM Owner's Name Address Phone ? Contract i Address License Noz- 7 Z4,tlftone ' TYPE OF W LL)P M NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. % PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' O Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing_ _ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ (Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Wall Destruction 11 Well Diameter Sealing Material {top 50'} Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONqi REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted If public sewer is Installation will serve: available within 200 feet.) Residence Jkf, Commercial Other 1 — Number of living units: —/— Number of bedrooms .-1V Character of soil to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Comparbmants PKC. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well," Foundation Property Line LEACHING LINE A No. & Length of lines Total lengthIs 1017 FILTER BED ❑ Distance to nearest: WellFoundation f � Property Line ,. SEEPAGE PITS Ar Depth._ „�� Sim . .� Number SUMPS l ❑ Distance to nearest: Wall' Foundation Property Line DISPOSAL PONDS ❑ 1 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, 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 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." IE The applicant must call for allmquired inspactI Complete drawing on re rse side. Signed Title: Date: a� Application Accepted FOR DEPARTMENT USE ONLY 1 by data /, Area Pith or Grout Inspection by Date Final Inspection b �S Y Date Additional Comments: ? LI Stk 466-6781 ❑ Lodi 389-3821 ❑ Manteca a23-7104 Q Tracy 8354M Applicant - Return all copies to: Environmental Health Pemrit/Services 1801 E. Hazelton Ave., P.O. Bot 2009, Stk., CA 9=1 l FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVBY DATE FERMIT'NO. INFO CASH ED 1 t4.z♦ IREV.1/B51 fro 01 �tlp lr-1Z b� 85-1 83 ..EH 142b L� o •