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_ APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT NoL�.+�c� c>� 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 �� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r> q - Womplete 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. f / l Job Address z City. Lot Size PM Owner's Name 1 Phone l f d C Contractor ddress � License No r4—S Phone 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONSI ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation } Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications F f 3 Public 171-Other Depth of Grout SealType of Grout — x I 1 Irrigation T Approx, Depth I 1 Eastern Surface,Seal.lnst5lle'd by. - Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction ❑ Welt Diameter """""'tSealing Materr"ial Stop 50'1 Depth Filler Material (Below 50') E TYPE OF SEPTIC WORK: NEW INSTALLATION L'.1REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.( Installation will serve: Residence— 16mm-eitial— Other rr i�,J� Number of living units: Number of bedrooms V� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ` -_ rc - Capacity No.fGompartments , f i PKG. TREATMENT'PLT. ❑ t ' „ Method of Disposal A n Distance to nearest: Well Foundation; Property Line 1 1 LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number I SUMPS Ll Distance to nearest: Well Foundation ## Property Line t DISPOSAL PONDS ❑ # I hereby certify that I have prepared this application and that the work will be done in accordance with Sari 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 riot 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,.l-shall employ persons subject to workman's compen�a / tion laws of California." The applicant ust c ireirTn3pections. Complete drawing on reverse side. E Signed Title: Date: -EPARTMENT USE ONLY ° i 1 Application Accepted by �_ Date 1 91 Area +t Pit or Grout Inspection by Date Final Inspection by Date a a Additional Comments: / 3 ¢ _ P ' , ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-710 ❑ Tracy 835 6385 * be Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �.. J - �_ " INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y ^p�A4TE� y�PERMITNO. + EH 13-24(REV.1/n 5) c7a9 �/ �"g gyp„'] - V I EH 14-26