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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT \J 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 0 ,� Application is heEeby 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. / Job Address City d Ti Lot Size PM - aW � Owner's Name 4C4 Address a� Phone Prl Contract,Q t� '�+ Address ' 4 - License No. Phone &3 TYPE OF WELL/PUMP: I� NEW WELL'❑ WELL R&PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ O,pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C3 Domestic I Private El Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ I I Irrigation �PApprox. Depth I I Eastern Surface Seal Installed by i - ' Repair Work Done Type of Pump H.P. State Work Done Well Destruction Typ fneter Sealing Material (top 50') epth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence commercial— Other f v Number o �,f living units: � Number of bedrooms — Character of soil to a depth of 3 feet: Water table depth ik SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ II Method of Disposal Distance to nearest:' Well Foundation Property Line iM LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation - Property Line I rt - SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property LineV DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance v�ith San Joaquin county ordinances, state laws, and l rules and regulations of the Sari 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' such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the f in "I certify that in7knctions. rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws Califor The app cant mu c II r all re uireComplete drawing on reverse side. Signed X Title: Date: I� FO ENT USE ONLY Application Accepted by Date b~ Area ` f �~... V. C� Pit or Grout Inspection by I Date _ -T Final Inspection by (4& Date '1 Additional Comments: Ay ❑ Stk 466-6781 ❑ Lodi�I 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. + EH 13-21(F1EY.I/x 5) i. EH 1CD 1-2fl T ?