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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA *'Z 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 /7, Q and A-/Dc-E City STIG✓ Lot Size PM a Owner's Name i�i Cly Jz fl S`Tz:-7P".) Address .4¢f/,-- Phone G e �ar� Phone 3` 7,0 ContractorF ___ �� Ldoa+� Address ��.�� S: License No. t�Y.rl-7 L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ' OTHER ❑ E 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 ' ❑ 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 ❑ Irrigation ___4pprox. Depth ❑ Eastern Surface Seal Installed by ` Repair Work Done ❑ Type of Pump .s State Work Done Well Destruction ❑ Well-Diameter Sealing Material 08p.'50') Depth (Filler Materia!-(Below 66.), TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is / f available 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: Y k Water table depth j SEPTIC TANK ❑ Type/Mfg } "; { Capacity No. Compartments 'r PKG. TREATMENT PLT. ❑ „^x � Method of Disposal Distance to nearest: Well Foundation Property Line P LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ; t I hereby certify that I have prepared thisapplication 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 owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 applicant must cl for all required-ins ctions-Complete drawing-on-reverse side.— Signed ide.Signed X Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 1 Area d_k N Pit or Grout Inspection 'Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi '369-3621 ❑ Manta823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services-1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 FEE AM�OUNT AMOUNT REMITTER RECEIVED BY DATE PERMIT-N-0. INFO CASH + EH 13-24(REV.1/s 5) 3 EH 114-28