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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA � � Telephone (209) 466-6781 ; 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 6 /t�o C # City ��T Lot Size Z16 PM Owner's Nam J 0%1 �- ditss ""4' �� hone I Contractor 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 [ �J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS '4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open_ —Bottom _❑ Manteca.-�•-----�Diaro#Well-Excavation Dia. of,Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ____�pprox. Depth ❑ Eastern Surface Seal Installed by c Repair Work Dane ❑ Type 4 f Pump H,P. StaterWork Done Well Destruction ❑ Well Diameter {t 4Sealing Material op 50'I' ► + Depth+ � xFiller Material 18elow 50' I TYPE OF SEPTIC WORK: NEW;INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION '.(No septic system permitted if public sewer is Failable 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 I Capacity 'LTNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line � 1 LEACHING LINE ❑ No. & Length of lines T Total length/size FILTER BED: ❑ Distance to nearest: Well tFoundation" " 4 Property Line SEEPAGE PITS ❑ Depth �-Size Number f SUMPS ❑ Distance to nearest: Well Foundation Property tine r DISPOSAL PONDS ❑ F r 1 I hereby certify that I have prepared this application and that thWwork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San 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 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 C ' rnia." The app' ant m call for all req ' d i tions. Complete drawing on reverse side. ` Signed Title: Date: FOR DEPARTMENT USE ONLY +� { �_�— 1 Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection 1by Date o//,?/ Additional Comments: H ❑ 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 4 ! FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMI7'NO. I INFO _ + EH 13-241REV.1/x51 EH 14-28