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R APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.;.STOCKTON, CA '-Telephone (209). .466-6781 f PERMIT EXPIRES�1 YEAR FROM DATE ISSUED, . , �� ,M .. . .. (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. p Job Address City Lot Size PM Owner's Name agg,6 - f O '`Phone Contractor Address 4a R ense No. Phone -6g � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM'REPAIR ❑ OTHER O 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r ❑ Irrigation ---Approx. Depth ❑ Eastern" Surface Seal Installed by Repair Work Done ❑ Type of Pump r H.PF- f' State Work Done Well Destruction ❑ Well Diameter Sealing Material.4top 501 Depth Filler Material IB610gw 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑"•REPAIR/ADDITION ❑I DESTRUCTION ❑ (No septic system permitted if public sewer is C�A available within 200 feet.) S Y•L h Installation will serve: Residence_ Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑: s ' f� g Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE No. &Lerigth_dfalrnn � �' Ttal length/size i FILTER BED ' ❑ Distance to nearestt Weft#5 rFoundation=.= _ Property Line SEEPAGE PITS �e Depth 2�a Size _ ~f. �-Number SUMPS ❑ Distance to nearest: Well _'f_.Foundation___5__d1 Property Line ' DISPOSAL PONDS ❑ ;�-++ -+ I hereby certify that I have prepared this,alpplication-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$ A_ q 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 r employ any person in such manner as to become subject torurorkgan'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 law f California." a The app cant ust call for FI quired" spections. Complete drawing on reverserside. Ni q 1�,' Y` Signed X t +� Title ` 4 113 11 ` , Date: FO DEPART ENT USE ONLY Application Accepted by Date r Area Pit or Grout Inspection by Date Final Inspection byDate Additional Comments: . t ❑ 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- CASH RECEIVED BY DATE PERMIT'NO. EH 13-24 1i1EV.r i e s) EH 14-28