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APPLICATION 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 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 I-J rS� t / k' } Lot Size PM City Owner's Name Address Qd3 Phone _ 8 L5/ate \ Contractor&"e a ,C la• Addres o r' G License No- 328-226 Phone TYPE OF WELL/PUMP: NEW WELL ffy 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 Weil Casing ❑ Domestic/Private Cl 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 Repair Work`Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Seating Material 1iop 501 ` Depth Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial— Other Number of living units:' z/ Number of drooms Character of soil to a depth of 3 feet: Water table depth /40 SEPTIC TANK �` f. Type/Mfg . Capacity 4 No. Compartments PKG. TREATMENT PLT':❑ \ / �� Method of Dispopal Distance to nearest: ..Well Foundation t� Property Line _ LEACHING LINE `x Rr'�No. & Length of lines Q Total length/size Q r t FILTER BED ❑ Distance to nearest: Well :/�/ Foundation 0 Property Line SEEPAGE PITS Depth 'Size Number SUMPS ❑ Distance to nearest: Weil�QQ Foundation_ Property Line S DISPOSAL PONDS ❑ tfA,�-`r 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." Contractors 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 applica ustcall for 1 eq 'ad inspections. Complete drawing on reverse std Q Signed X Title: �" Date: O t FOR DEPARTMENT USE ONLY Application Accepted by I Dateot G Pit or Grout Inspection by Date Final Inspection by Date J 6 } �? /, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca -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 AT CASH RECEIVED BY DATE PERMIT'N0. + EH 13-24(REV.I/x 5) `fi Ek 1428 (f