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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA y� I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 . (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. i. Job Address City Z144 Lot Size PM F Owner's Name y Address �� Phone Contractor's Name JO:U ,? license No. az Phone - TYPE OF WELL/PUMP: NEW LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION jM\ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK '`SEWER LINES DISPOSAL FLD. PROP. LINE F 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 f A Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f ❑ Irrigation ft2_Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane ! -�s✓� Well Destruction 171 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 units: Number of bedrooms Character of soil to a depth of 3`feet: x' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ M6thod of Disposal ' Distarice to nearest:t Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:l Well Foundation Property Line i SEEPAGE PITS ❑ Depth T Size Number fSUMPS ❑ Distance to nearest Well Foundation Property.Line ,- DISPOSAL PONDS ❑ I t 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 r 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 su nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: " ce 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 req spections. Complete drawing on reversede. 4. L Signed Title: 7date: �., FOR DEPARTMENT USE ONLY Application Accepted by Date " Area 5 ' Pit or Grout Inspection by Date Final Inspection by Date: "'Additional Comments: r ❑ Stk 4664781 Lodi 369,3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 ,= Return pp Alicant- Retn all copi s to: Environmental Health Permit/Services 1601 E. Ave., ,Hazelton Ave. P.O. Box 2009Stk., CA 95201 gV r _ tier FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE 1 PERMIT"NO. INFp CASH �+ EH 1344(REV.10/831 EH 14-28