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J _ a APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE_ STOCKTON, CA 'Telephone (209) 4i%-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s (Complete in Triplicate) , Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei' 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 s Local Health District. " 1. SIS ., Job Address K City. r Lot Size PM l Owners Name` 4 (� [l Add �' res �t��-{.�+S�Qy,. Phone � o/ Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ �' OTHER ❑ DISTANCE TO NEAREST: SEP. ANK SEWER LINES DISPOSAL FLD. PROP. LINE v FOUNDATION AGRICULTURE WELL PITTTSUWS INTENDED USE TYPE OF WELL PROBLEM A N SPECIFICATIONS ❑ Industrial ❑ Open Bottom nteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel P ❑ Tracy Type of Casing t g ❑ Public l er _ Specifications ❑ Delta Depth of Grout Sealr r Ty e.of Grout ❑ Irrigation 1j--gpprox.•Depth ❑ Eastern . Surface Seal Installed by Repair Wo r one ❑ Type of Pump H.P. State'Work Done Well Destruction , ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is i -available within 200 feet.) _ : .. Installation will serve: Residence_ Commercial�, Other ,,�•_ Number of living units: ; Number of_bedrooins y s f Character of soil to a depth of 3 feet: ' 4 Water table depth " SEPTIC TANK LJType/Mfg^- - 3 Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property,Line �" i LEACHING LINE ❑ No. & Length of lines Total length/size _ y FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size . Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. Home ower 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."Contractors 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-" i The applica t call for all requir�'ctions. awing on reverse side. Signed X r/i ZZQ Title: Date: � F DEPT USE ONLY _ I Application Accepted by Date Area a Pit or Grout Inspection by Date Final Inspection by Data Z Additional Comments: ❑ Stk 466-6781 _ ❑ Lodi 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., CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED C INFO RECEIVED BY DATE PERENO,H 4-26+ EH t3-24IREV. � t