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APPLICATION FOR PERMIT SAN JOAQ�,i#V LOCAL HEALTH DISTRICT 1601 E. HAZE T,ON AVE.; STOCKTON, CA Telephone (209) 466-6781 } • I 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. JellJob Address /VoST-0 7'1��/�Y/� /�G( - City Lot Size PM ' . . �� _/-��7 lrY t � �J � Owner's Name � Address Phone Contractors` Address License No. 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. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p ! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 .t i ;# Depth r ` —Filler_Material-(Below 50'1 ---- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic.system permitted if public sewer is 4 ' --available within 200 feet.) l Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms4 Character of soil to a depth of 3 feet: t ' p _ Water table depth SEPTIC TANK ❑ Type/Mfg �" Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �- .—Distance to nearest: Well Foundation Property Line 1 t!D LEACHING LINE ©, No. & Le:ngthSaf lines _ Total length/size ' FILTER BED ❑.-Distance to.nearest well Foundation Property Line SEEPAGE PITS ❑ Depth r Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J 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 } 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 required inspections. Complete drawing on reverse side. Signed Title: a w to+" Date: (' - i OR DEPARTMENT USE ONLY Application Accepted by __4k - — Date Area Pit or Grout Inspection by Date Final Inspection by Date f/—�'! 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH+ EH 1428 rRkll.�-LiH s1 j . {"'1•�