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t i � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-$781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED v' [Complete in Triplicate) <, Application is hereby made to the San Joaquin Local Health District fora 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 Ryles and Regulations of the San Joaquin 'Local Health District. Job Address Z4 24 a City _ of SizeAIWX s-rCJ PM Owner's Name � �• Address' 7-4 4 (2-40( phone` t Contractor ddress License NgJ�`+"-�7' Phon 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 k INTENDED USE TYPE OF WELL. PROBLEM AREA--GONSTRUCTION'SPECIF]CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing it ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing" Specifications ❑ Public ❑ Other D'Delta Depth�f,.G out Seal Type of Grout ❑ irrigation ---Approx. Depth ❑.Eastern Surf " ace Seal Installed by �. I Repair Work Done ❑ Type of Pump H.P. State Work Done J Y Well Destruction ❑ Well Diameter f Sealing Material (top 501 `►�. Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) { Installation will serve: Residence_ Commercial Other j Number of living units: Number of bedrooms . ' Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT:71 Method of Disposal' ' GDistance to nearest: r WeII Foundation Property Line X .r LEACHING LI -No. & Length of lines Total length/size W?� FILTER BED ❑ . Distance to nearest: Well v _ Foundation �� _ Property Lire SEEPAGE PITS �+pepth y Size � � Number SUMPS - ❑ Distance to nearest: WeII gym' Foundation v �_ Property Line OISPOSAL PONDS �❑ I hereby certify that I have prepared this application and that the work will be'dbne 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, 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 must call for all re uireMinspecns. Cqoglplete rowing on reverse side. F Signed Date: Title: " � —1� - FOR DEPARTM USE ONLY i Application Accepted by - i ��5FDate AreaPit or Grout Inspection by Date �Inp,.vin oby . �` Date 113, Additional Comments tk 466-6781 El Lodi 369-3621 El Manteca 823-7104 EJ Tracy 835-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE _ PERMIT NO. +EH 13-24 1 REV.1/s 51J-A EH 14-28 �y -Ly)