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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. 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®� So,, OXAAJ M&�_7 Cit Lot Size PM C Owner's Name Address Phone l � Conhacto Address Q '3� icense No, d2-2- Phonemes TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ( SYSTEM REPAIR I( OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN7X� u 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 0 Gravel Pack ❑ Tracy Type of Casing Specifications KPublic 5 Other Ll Delta Depth of Grout Sea] Type of Grout I I Irrigation —..Approx. Depth I I Eastern Surface Seal installed by Repair Work Done A- Type of Pump_ H.P.I�]]� State Work pone Air Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') -- TYPE= OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l ) DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) ' I Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms *� Character of soil to a depth of 3 feet: `' '~ Water table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation y Property Line LEACHING LINE ❑ No. & Length of-lines. Total length/size FILTER BED ❑ Distance to nearest: !Well -"'Foundation Property Line SEEPAGE PITS i I Depth, Size Number SUMPS Ll Distance to nearest: Well Foundation Property line DISPOSAL PONDS ❑ 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 0 rules and regulations of the San Joaquin Local Health District. I r 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 taws 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,1 shall employ persons subject to workman's compensa- tion laws of California." " The applicant must call for ail required inspections. Complete drawing on reverse side. Signed X� Title:i.[.Ld� Date: f FOR DEPARTMENT USE ONLY l` 3 l Application Accepted by Date Area i Pit or Grout Inspection by Date Final Inspection by 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 CK FEE AMOUNT DUE AMOUNT REmmrE[7.+ CASH RECEIVED BY DATE PERMIT"NO. INFO Q +.EH 13-21(REV.I/H 5) Q� ^� EH N-26 1 — 1