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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 TYEAR FROM DATE ISSUED F (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. Job Address 6 �i City4_ftCy Lot Size PM Owner's Name Phone Address k � �.�+.,...,..�.-�..,.,... �.� ...c-, ..+�...... �=tet... ...._......e. -�._..:.�.,-.-,.-^.,,...---,••--_�.. --,«ti�..r-„�.,.-�,..� Contractor Address O f 14 q License No.,9.Zr2�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 i_ OTHER WELf_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS } ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel Pack Ll Tracy Type of'Casing } Specifications I'1 Public ❑ Other _ F7 Delta Depth ofGrout Seal � Type of Grout I I Irrigation -.Approk. Depth l 1 Eastern Surface Seal Installed by Repair Work Done E3Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 i Depths Filler Material (Below 501 t — TYPE OF SEPTIC WORK: NEW INSTALLATION ILj. F EPA IS/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence eCommercial— Other Number of living units: M"� 1 Number offbedrooms depth - i Character of soil to a th of 3 feet: 1,4AAK A P. Water table depth SEPTIC TANK Type/Mfg e. G iDe6-� Capacity — No.fCompartments PKG.' TREATMENT PLT. ❑ r If Method of Disposal I Distance to nearest: Well 8 t) Foundation 1 Property, bne Sb JII LEACHING LINE { No. & Length of lines ` a Total length/size w FILTER BED ❑ Distance to_nearest: Well Foundation Property Line !f SEEPAGE PITS l I Depth Size ` r Number I SUMPS 11 Distance to nearest: Well Foundation �• � T Property_Line DISPOSAL PONDS ❑ 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 Di§trict, 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.'- CQtttractof s hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." -�- �• - "` Theapplicant must c it for all req uir in ctions. Complete drawing on reverse side. Signed X Title: Date: t/ la DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT NO. ♦.EH13-24iREV.1/x51 INFO �v� 1.f r 7V/-�� EH 1420 I,,