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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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. f Job Address I- � � 1 G�r � City 'Nk4pt Size PM Owner's Namedh.� 4-L.S01-• Address _ LS ��"'r `+} Phone 1 Cori"tractor's Name iranse Na. � 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 -.._ - - - FOUNDATION. .-=:-.AGRICULTURE,.WELL;. -- ----O.T,HER WELL —PITS/SUMPS-_..- ------N- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_,, Specifications v ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout T1 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter I Sealing Material atop 501 0 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION C1 DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence�mmercial_t Other Number of living units: Number of bjodrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK f3- Type/Mf6 CapaciNo. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest. Well Foundation Property Line i al LEACHING LINE M__Nlo. & Length of lines Total length/size j y FILTER BED ❑-Distance to nearest: Well Foundation Property Line s f +SEEPAGE PITS ❑ Depth SizeNumber SUMPS ❑ Distance to nearest: WeII,! 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 Joagdin•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- ion laws of Callfbrni " The a n u t c II fo a req it d in pe omplete drawing reverse ide. Signe Tine: � �� Date: FOR DEPARTMENT USE ONLY Application Accepted by _ d-D��Stirva..__� x Date Area p Pit or Grout Inspection by Date Final Inspection by - Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 —Applicant w Return all-coples-to:-Environmental-Heafth-Permit/Services 1601-E-.-Hazelton'Ave.,-P.O.-Box 2009, Stk.,CA-95201-- -----FEE ----� INFO AMOUNT DUE y AMOUNT REMITTED � .SH K IF RECEIVED BY DiATE PERMIT"NO. +EH 13-24IREV.10/831 A) EH 1428 ✓