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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 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. 1852 for well pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address '` City � C9 Lot Size PM [ yr% r/, � Address �YY1 -2 Phone I 7 913 7 Owner's Name Contractor S� l _Address-a te^ -.License No. Phone I f TYPE OF WELL/,PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-=:O a z- PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER O DISTANCE TO NEAREST:YSEPTIC TANK SEWER LINES r aDISPOSAL.FLO. -. PROP. LINE FOUNDATION AGRICULTURE WELLI;- _, OTHER WELL PITS/SUMPSa INTENDED USE TYPE OF WELL PROBLEM ARTA-,-CONSTRUCTION SPECIFICATIONS � { ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy�' j4.-V Type of Casing l Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout SealType of Grout EJ Irrigation —Approx. Depth 171Eastern Surface Seal Installed by ' Repair Work Done Cl Type of Pump H.P. State,Work Done , Well Destruction ❑ Well Diameter Sealing Material Itop 501 3 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:.. NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION. INo septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence_ Commercial Other i Number of living units: Number of bedrooms �-9» ti4..= Water table depth Character of soil to a depth of 3 feet: �_�' P SEPTIC TANK ❑ Type/Mfg � � Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth -SiieJ'"' "' Number SUMPS ❑ Distance to nearest: Well Foundation ` Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that thework 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 admpensation`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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for II requed 1 spections. Complete drawing on reverse side. r h Signed Title:_ �� Date: i 9 _ I FOR DEPARTMENT USE ONLY i Application Accepted by _ - — ""'-Date�FJ'� �� Pit or Grout knspection by + ' '_ Date Final Inspection by,11Aate t o��Jam` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO /► r + EH13-24(REV.1/e 5) �S © - b�sl FIS b X5.75 EH 140 F _