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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466=6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED (Complete in Triplicate) 4-ti : ": 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 Ordinan a No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. �• Job Address City� �Lot Size g�o"�C'PCS PM Owner's Name Address oe�7 - Phone Contractor Address..... c9G`�a � 3 License No. y Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION _ AGRICULTU RE.WELL _ _- ._. OTHER-WELL--- - PITS/SUMPS C) INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Fxcavation Dia. of Well'Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type T of Casing -- -_ _ _ Specifications ('0 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx.`Depth ❑ Eastern Surface.Seal Installed by Q r Repair Work Done...-El-,_.--Type of Pump - H.P.. + State Work Done Well Destruction t ❑ Well Diameter ( Sealing Material (top 50') Tt Depth ( Filler Material (Below 501 TYPE OF SEPTIC WORK: "NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is - available within 200 feet.h i Installation will serve: Residence_ Commercial__ Other Number of living units:I/--- Number of bedrooms Ir Character of soil;to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT:'❑ Method of Disposal n Distance to nearest: Well Foundation Property Line LEACHING LINE - o &'Length.of,lines- _`/6 _ Total length/size. FILTER BED ❑ Distance to nearest: Well Foundation Property Line 3 SEEPAGE PITS K7/Depth 42��- r' Size _ Number t SUMPS ❑ Distance-to nearest: ►WeII Foundation Property Line f DISPOSAL PQNDS ❑ ( r 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. Home owner or licensed agent's signature certifies the following: "l 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 Califor.-a-- The applicant st II forrequ iris ction ompl a drawing on reverse side. Signed f C�'h1� i Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by CD.cw. '. o. Yw^ Date Area d T Q Pit Grout Inspection by , a�'�u�?� ,� -re Final Inspection by Date - $i r 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH t3-24,MEV.1 8t8) L - EH