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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E�- HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED IComplete 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. Job Address ,yy� Lot Size[} PM Owner's Name V /,.,:],ITI /`�r/ i� _ -- _ Address ! l/G_ i///��/LS-/'AZ/�_ Phone / ^a ContractorR �t!/Y 5 Address License No. /� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL `OTHER WELL r-PITSISUMPS o71Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N a ❑ Industrial ❑ Open Bottom '❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private WGravel Pack ❑ Tracy Type of Casing Specifications i7 Public �❑ Other i Ll Delta Depth of Grout Seal Type ofof,–�Grout I 1 Irrigation pl�Approx DepthI 19E�astern S ace Seal Installed by Repair Work Done ❑ Type of PumpP H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_.. Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:/ Water table depth SEPTIC TANK ❑ Type/Mfg, tk Capacity No. Compartments PKC. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line � t LEACHING LINE ❑ No. & Length of lines Total length/size } FILTER BED ❑ Distance to nearest: Well Foundation Property Line I r SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Joaquin Local Health Di§trict. 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: "l 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." Theapplicant m all requ' tions. Complete drawing on rev��sa side. �7 Signed X _ Title: Date: /;2`�— U t� FOR DEPARTMENT USE ONLY 2 Application Accepted by Date Area v Pit or Grout Inspection by Date Final Inspecti by Date l��l .- - , Additional Comments: "� ❑ Stk 466-6781 ❑ Lodi -3621 O Manteca 823-7104 . ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH 1324 IREV.Ii H 51 % ®� 9 ✓`�,iXb ✓ } EH 14-2e ! 1 v V