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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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.TMs 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 ,lam z? z,. '�J�" e;1 010 11 a:2 1 QP;/ .:? / s Owner's Nam Phone 00, Contractor's Name ense No. _ y - Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 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 SPECIFICATION _ ❑ Industrial A-000—Bottom ❑ Manteca Dia. of.Well Excavation ZZ Dia. of Well Casing ©'la m'estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications e ❑ Public ❑�-Other ❑ Delta Depth of Grout Seal Type of G I ❑ Irrigation A��Approx. Dept ❑ tern Surfarga eal Installed by ✓ Repair Work Done ❑ Type of Pump KH P. Z State Work Done Well Destruction ❑ Well diameter Sealing Material (top 50') 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.) !. • Installation will serve: Residence Commercial_ Other Number of living uriits: Number of bedrooms � I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ f �' " �, Method of;Disposal—- Distance to nearest: Well's J Foundation Property Line f LEACHING LINE ❑ No. & Length of lines ~"'' Total.length/size ---- FILTER BED ❑ Distance to nearest: Well Foundation Prro a �'3 1 p rty,Line „e SEEPAGE PITS ❑ Depth Size Number k SUMPS ❑ Distance to nearest: Well Foundation _PropertyL iiie DISPOSAL PONDS ❑ ; c hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county d nces, state laws,1 1and i 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 California." The applicant mu Il for all required inspections. Co le drawing on reverse side. Signed X Title: __ __..._� Date: � t OR DEPARTMENT USE ONLY + Application Accepted by II Qate �� o^� Area" {� 1 Pito Grout pection b (�O N� .\J "" Area- 101)x0(2 9A.� �� y Date Final Inspection by �eyu Date L 1-al Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $35-6385 h Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED C K H ^RECEIVED BY DATE PERMIT"NO.' + EH 13-24 3-26IRE'V.14!$31 C) EH 114-26 114-263 X05. 0