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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 DAT_E 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. Job Address T� t�U I@ZZA,1, City G Lot Size !!�4 G PM Owner's Name /�Z24 4,7-0Address Phone Contractor r i� Addresser /+� License 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I i Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well.Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPt OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ) DESTRUCTION I i INo 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 sail to a de of 3 feet: p µ depth Y Water table depth SEPTIC TANK -❑ Type/Mfg ____- p ... Capacity No. Compartments PKG. TREATMENT, PLT. © r— Method of Disposal Distance to nearest:. Well Foundation Property Line ' a LEACHING LINE No& Length of lines Total IJr gth/size FILTER BED ❑ Distance to nearest: WellT Foundation Iff� Property Line _ SEEPAGE PITS I i Depth 10 �. Size ,?) Number__1 SUMPS ' Distance to nearesvl Well r Foundation 4�7'07" Property Line�5 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 Dstrict. .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 tail for requir d inspections. Complete drawing on reverse side. Signed X_ Title:'—' Date; FOR IRAFLTMENT USE ONLY Application Accepted by Date %/ Y Area Pit or Grout Inspection by Date Final Inspection by "''" Dated Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 .n INFO AMOUNT DUE AMOUNT REMITTE$' T CASH RECEIVED BY DATE PERMIT'.NO. "`"` +.EH 13-24(REV.1/"5f