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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 (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. t y Q �� Job Address 1�5L?Q k• 1-1 i1 Tr 1��e ��``' Cit Lot Size PM ki e p Owner's Name Address �O n Phone tdt -:34 00 Contract ` r �x� Phone S� Address �� License fVo,_ ;Ji 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 FI Public LI Other ❑ Delta Depth of Grout Seal Type of Grout _J. I I irrigation _Approx. Depth ( 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 1� Depth Filler Material (Below 50') e� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION ( I (No septic system permitted if public sewer is \ available within 200 feet.) Installation will serve: Residence X Commercial Other r Number of living units: A— Number o bedrooms Character of,soil-to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity�� .__ __ No. Compartments PKG. TREATMENT PLT. ❑ ( t Method of Disposal Distance to neatest: Well E— Foundation %0 Property Line 15 onf d LEACHING LINE >�f No. R Length of lines V Total length/size X FILTER BED ❑ Distance to nearest: WellSo` Foundation�Q _..__.- Property Line Al _ SEEPAGE PITS �L Depth Size 3, Number SUMPS Ll Distance to nearest: Well �Dr Foundation o f 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 Oiltrict. Home owner or licensed agent's signature certifies the fallowing: "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 taws of California." The applicant mu all for alk uir inspections. Complete drawing on reverse do Signed Title: ' ' Date: 0 FOR DEPARTMENT USE ONLY f Application Accepted by Date / Area �] 1 Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Menlace 623-7104 ❑ Tracy 835-6385 ��(\ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE ®� INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE {� �P�ERMIT'No - +.EH13-24 IHEV.r/x 51 10, 66 G /z f[� ��`/ a (�" •-/�� EH 14-ZB V