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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA -Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : r h .(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 Aegulations.of the San Joaquin ` Local Health District: F Job Address City Lot Size /. '� :^_PM Owner's Name Address Phone Contractor Address License N Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 5. A 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 Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type.of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by rNN 34:*;?•, Repair Work Done ❑ Type of Pump H.P. State.Work Done 1i Well Destruction ❑ Well Diameter Sealing Material Itop 50'I y1.Ja f+ Depth - : Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION>C REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f available within 200 feet.) k Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 17 Type/Mf capacity�� No. Compartments IF PKG. TREATMENT PLT. 0 4. Method of Disposal Distance-to nearer Well•---- - Foundation """""Property Line LEACHING LINE Nod & Length of lines 1 H Total length/size *-k y S FILTER BED ❑ Distance to nearest: ,WeU.."" da - Fountion Property Line� SEEPAGE PITS ❑ Depth "" Size Number01 SUMPS ❑ Distance to nearest. -Weill Foundation Property Line DISPOSAL PONDS ❑ e f F 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, i shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractoi's hiring or sub-contracting signature certifies the following:"I certify that in the performanca o e work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif ornia. <uti w j The applicant mi�teatbfor all r dins ction o plate drawing on reverse side. Sign 4 ) Title: Date: 5�2� { EPARTMENT USE ONLY Application Accepted by qA, Date_4:A9"S-_7 Area y� Pit or Grout Inspection by Date Final lnspection.by. 2, � Date ��U Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - Tracy 635-6385 Applicant- Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 I I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.I a 51 �D- EH 14-28 ,f' ✓✓ Y .