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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. { C Job Address [�v 5 CityCob I Lot Size OM i Owner's,Name Address Phone `Contfactok lLf�� ` D �I Address IO � License No. 3 d n Phone TYPE,OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT' FOUNDATION AGRICULTURE'WEL'L.- OTHER WELL PITS/SUMPS- INTENDED ITS/SUMPSINTENDED USE i--,TYPE'OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottorff ❑ Manteca Dia. of Well Excavation Dia: of Well.Casing \ '• R h. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` FI Public ❑ OtherF { n Delta Depth of Grout Seal ' � - - "�'Type`ofGfout' JI I I Irrigation —.-Approx. Depth I_I Eastern Surface Seal Installed by '4 Repair Work Done ❑ Type of Pump -- H.P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing.Mater4t.ltop 50') r Depth - ,Filler"MateriallIBe4ow 507 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I. /ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence mmercial— Other k Number of living units: Z_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Capacity No. Compartments t PKG. TREATMENT PLT. ❑ .�. l t Method of/DisosaJ Distance to nearest: Well Foundation L Property Line LEACHING LINE ft4--1To. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation I-AS 1 Property Line . e SEEPAGE PITS "--15epth Size gN^�umber SUMPS Ll Distance to nearest: Well Foundation r17j{0 Property Line _ DISPOSAL PONDS ❑ ., 4 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,d I rules and regulations of the San Joaquin Local Health District. - 7 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 shalt not any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies t Ilowin . " 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 Z*aftr4a." pplica mu II for l to drawing o everse si . .1 . -� " Signe Title: Date: 4 FOR DEPARTMENT USE ONLY _ Application Accepted by Date U Area _-�_ - - J or Grout Inspection by Date q -' Final Inspection 6y�Od> Date Additional Comments: ❑ Stk-7 466-6781, ❑ Lodi-.369-3621-❑-Manteca-823 7104-0-Tracy-'835-6385— Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY HATE EPERMIT*EH 13-241REV.v/M5f70� )D_C/�S� �EH 1429 < t7f O /