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I 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. City ,4G Lot Size �L PM Jab Address Address T A Phone Owner's Name ��sr Contractor L� ►CrrIL Address d License No.,J71 a Phone �� 7 - TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _OTHER-P r 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.sof Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifii5ations ❑ 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 Sealing Material (top 50.1' Depth Filler Material (Below,50'1 '• J TYPE OF SEPTIC WORK: NEW INSTALLATION 7Q REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system tem permitted if public sewer is avaInstallation will serve: Residence— Commercial Z'177 Other .- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: P O Water-table depth SEPTIC TANK ❑ Type/Mfg _ �kl Capacity Z.-212V No. Compartments ,J PKG. TREATMENT PLT. ❑ t--i j Method of Di n Distance to nearest: Well Foundation �d Property Line o,`00 -- r LEACHING LINE )4�. No & Length of lines �! �T, Total length/size FILTER BED O Distance to nearest: Well Foundation/i4 Properxy_Line ._ SEEPAGE PITS ❑ Depth Size ., Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 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,al 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 laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed �s(J Title: %�"�''"c"�C/ Date: 5 6 � �FOZRPARTNIENT USE ONLY Application Accepted by Date Area �^ Pit or Grout Inspection by Date Fina}Inspection by Dar y � •a Additional Comments: ❑ Stk 466-6781 ❑:Lodi 369-3621 C1 Manteca 623-7104 El Tracy $36395 - { Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 4 FEE AMOUNT DUE AMOUNT REMITTED CASH RE-CEIVED`BY: DATE PERMITN0. INFO + EH 13-24(REV.t/®5) EH 14-28 " .e: