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k: 3 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 F 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 welUpump and the Rules and Regulations of the San Joaquin Local Health`District. #! Job Address "1 r City Lot Size �~�/ PM Owner's Name 7 d ss Phone Contractor Address License No. Phone 7Z�g?0/TYPE OF WELL/PUMP: NEW WELL ❑ '" WELL REPLACEMENT_ ❑- DESTRUCTION ¢PUMP INSTALLATION ❑ SYSTEM REPAIR El' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL � OTHER WELL PITS/SUMPS INTENDE6 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ¢ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout --- I i Irrigation --Approx. Depth l I Eastern Surface Seal Installed by - _ Repair Work Done ❑ Type of Pump H,P. .:State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'), Depth 1 Filler Material (Below 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence s Commercial Other e Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK ❑ Type/Mfg . Capacity rbc/ No. Compartments PKG, TREATMENT PLT. ❑ r? undation �] Method of Dispos Distance to nearest: Well e— - i ti� Property Line LEACHING LINE ❑ No. & Length of lines ` TpW length/size FILTER BED 171Distancejto nearest:Well undation / Property Line f � SEEPAGE PITS ['I Depth Number t< SUMP UIDistance to nearest: Well undation! D ',Property Line /12 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 District. i 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 a 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- ffi tion laws of California." r The applicant mw o r it "i spections. m e drawing on erse side. Signed" Title: -� Date: f i FOR DEPARTMENT USE ONLY Application Accepted by 1 Date.] Area _ �f Pit or Grout Inspection by a Date 7 Final Inspection by" %l Date Additional Comments: 3 ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7184 ❑ Tracy 835-6385 jI Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 I } FEE INFO AMOUNT DUE, AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. t EH 13-24{REV-I/x sr *- EH 14-26 O 7 /