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09 A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (Complete in Triplicate) I Application is hoteby 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Addresses City Lot Size PM M Owner's Name J�, .> '�. Address �� Phon} 4` Contracts �_ C� _ Addres,:;,)536Y r License NP11� Phon� -C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIPLD._ PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL T PROBLEM CONSTRUCTION SPECIFICATIONS _._ ❑ Industrial ❑ Open Bottomnteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel P ❑ Tracy Type of Casing Specifications { 1-1 Public C1 r ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation _ _Approx. Grout— Depth LI Eastern Surface Seal Installed by _ Repair Work Do ❑ Type of Pump -- t H.P. State Work Dore Well Destr ton ❑ Well Diameter r Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l'l REPAIR IADDITION LI DESTRUCTIO iNo Septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence_ Commercial_ Other i Number of living units: Number of bedrooms _ a Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation ' Property.Line 8 LEACHING'.LINE Cl No. & Length of lines 1 Total length/size } FILTER BED ❑ Distance to nearest: f Well Foundation Property Line d SEEPAGE PITS i I Depth Size r Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 ust call for all-requir d inspections. Complete drawing on reverse side. Signed X Title: Date: - 7-0—T? FOR DEPARTMENT USE ONLY /� Application Accepted b ,' d' 7 k PP P y � Y Date Area Off i Pit or Grout Inspection by Date Final Inspection by "" Date Additional Comments: 5J'3 0 r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ', , ';"0 Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E"Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE C INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED$Y DATE PERMIT-NO. EN 1428 +.EH 13-24(REV.F/H51 � 'i l�