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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 i, made incompliance 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. f Job Address �� LA�?3 rAA City t Size PM Owner's Name .p� Address r+�Phone / Contractor {�U—Co w 3 I Address Q C- License No. d��` Phone $Jp X11— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well Casing 1> ❑ Domestic/Private ry❑ Gravel Pack Tracy Type of Casing Specifications- F1 Public 1� Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation prox. Depth I 1 Eastern rfece Seal Installed by' " Repair Work Do�EC] Well e of Pump H.P. State Work Done Well Destru Diameter` Sealing Material atop 50') Depth Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I ESTRUCTION I I (No septic system permitted if public sewer is available within 200.feet.) Installation will serve:' Residence — Commercial_ Other a Number of living units: Number of bedrooms -_ Y .s,�. r $ k Character of soil to a depth of 3 feet: Water table depth ^ „ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. OL ► Method of Disposal Distance to nearest: Well .Foundation Property Line : l LEACHING LINE C4--fsro& Length of lines � `� _- Tofal length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ) Depth Size_ Number SUMPS 1_71 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 'S I hereby certify that I have prepared this application and that the work All be done in accordance with San Joaquin county ordinances, state laws, and i 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."Contractor's hiring or sub-contracting signature es 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 California." � z T e applican call or 11 re ired ' lets drawing on reverse si r�r ned_. Title: -Date:- - FOR DEPARTMENT USE ONLY Application Accepted by Date Area ©� Pit or Grout Inspection -- Date incl Inspection by, .-. _ __ T_ 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 AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24(REV.r/951 �Q Q � X ;7��.d / EH 1420 V - /