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v x APPLICATION FOR PER ,SIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE`ISSUED �i (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. Job Address Cityaach 6 �ize PM # � I Owner's Na Address Phoney Contractornii Address License No. ! Phon TYPE OF WELL/PUMP: ELL ❑ WELL REPLACEWW ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' l'1 Public ❑ Othei 1=1 Delta Depth of Grout Seal Type of Grout_.. _ I i Irrigation __4Apprax. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump IH.P. State Work Done i — Well Destruction ❑ WeII�-Diameter Sealing Material Itop 50'1 Depth - Filler'Material (Below 50')-..l. _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I F DESTRUCTION I. INo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units:-!��- Number of bedrooms j Character of sail to a depth of 3 feet:; Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT.-Li Method of Disposal f Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED r ❑ Distance to nearest:- Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 Di1trict. 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." The applican ust call for all requir nspecti ns. Complete drawing on reverse side. �/�/—c7�] R l R li Signed X Title: Date: V FOR DEPARTMENT USE ONLY ` i Application Accepted by Date w aq6 1 Area\- ij *_ Pit or Grout Inspection k i� Date Final.lnspection b.y Dater Additional Comments _r� ❑ Stk 466-6781 ❑ Lodi i 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ]DATE PERMIT'NO. +-EH13-24{pEV. �-�i_) S. �� 1 QX: f�/r c `I"�� E 14-26 H t n' I