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APPLICA ON 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 (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 Cqunty 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 i ! Lot s=e - PM Owner's Name Address (9 (� one 7 S� �I Contract j Address Jib, *l / c� License No. vc�sato 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 Wel Excavation' Dia. of Well Casing ❑.Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications i n Public (7 Other F1 Delta Depth of Grout Seal Type of Grout 1 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 501. Depth "ler:Material (Below50') TYPE OF SEPTIC WORK:, NEW INSTALLATION L7/REPAIR)ADDITION DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial X Other, Number of living units: . Number of bedr2orylsr' Character of soil to a depth of 3 deet: _ ,• N / t Water table depth Q '� SEPTIC TANK ❑ Type/Mfg Capacity PKG. TREATMENT PLT. El a `" No. Compartments+' f Method of Disposal ^ Distance to nearest: Well f `Foundation ti. + i Property line f LEACHING LINE No. & Length of lines Total'length/size' 1,00 Y. FILTER BED ❑ Distance to nearest: W'll .-/ODr, O Property Line �.-� :'* r Foundation ._ SEEPAGE PITS Depth Size Number 4,. SUMPS Ll Distance to-nearest:` Well D r ` / ` r - - Foundation' ��, Property Line DISPOSAL PONDS ❑ �� I hereby certify that I have prepared this application end that the work will be done in accordance with San.Joaquin county ordinances, state laws, and r rules and regulations of the San Joaquin Local Health Diltrict: /' t Home owner or licensed agent's signature certifies the ftilloviring: "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 subiect,o wo-rkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of.&work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must II for allir inspections. Complete drawing on roveIde. Signed Title: Date: FOR DEPARTMENT USE ONLY Q Application-Accepted by Date v f 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 - INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ",.ak PERMl7 NO.CASH DATE. +.EH 13-24(REV. l n 51 `�q � EH 14•2$ J V ff !/