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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 6' 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. r. Job Address V � City Lot Size- d4:, � PM Owner's Name 1 ` - Address Phone�y" n Contractor r 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ 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 _Approx. Depth ❑ Eastern Surface Seal Installed by r�} Repair Work Done ❑ Type of Pump H.P. i - } State Work Done Well Destruction LlWell Diameter Sealing Material (top 501 i ,L o Depth Filler Material {Below 501 x TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is l T , 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: on 4- } - Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity_ ;No. Compartments PKG. TREATMENT PLT. ❑ Method of Disp Distance to nearest: Well 10 8 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size -. FILTER BED ❑ Distance to nearest: Well IC-)0 Foundation Property Line SEEPAGE PITS ❑ Depth Ir Size Number SUMPS z" ❑ Distance to nearest: Well /570— Foundation U Property Line DISPOSAL PONDS. ` ❑ i . . r hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 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 California." r The applicantAust call for all uired inspections. Complete drawing on reverse side. 'x 1. Si ned• Title: �t Date: 2— 0 O /` FOR DEPARTMENT USE ONLY Application Accepted by r � Date 7-7 ,1 --!Area Pit or Grout Inspection by r Date J(L(L� Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3W-3621,'" ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEF INFO AMOUNT DUE AMOUNT REM{TTED CASH RECEIVED BY DATE. PERMIT•NO. + EHi3-24SREY.t/esl �('1 ','i�7— EH 142a V [6 f l _3 ! q