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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 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/of install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. a Job Address / �!b7l P r! ? �r�1 Cit 501 l Lot Size PM M" jr14 tJ-TecA- Owner's Name i'� �2.!f+C�a Address Phone Contractor 0,gkAA1to 6)KTry,A10_ Add ressStf Lt) -�' �T 0igr,C�A�LicenseNo. ��GIS Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL! PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom_� Manteca- Dia. of Well Excavation Dia. of Well Casing F ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications T'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by _ E Repair Work Done. ❑ Type of Pump H.P. State Work Done Well Destruction , ❑ Well Diameter Sealing Material (top 50') Depth jr Filler Material l8elow 501 [ TYPE OF SEPTIC WORK: NEW INSTALLATIONt' REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) (� Installation will serve: Regidence Commercial_ Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Tti Lr Capacity No. Compartments PKG. TREATMENT PLT. ❑ w Method of Disposal s ,r Distance to nearest: Well Foundation Property Line LEACHING LINE ;_9( No. & Length of lines Total length/'size avo FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size 2) 1r/2 Number . SUMPS L-] Distance to nearest: Well 1 _ Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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." Contractors hiring or sub-contracting signature certifies the following: "l 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." t The applicant must call for ail required inspections. Complete drawing on reverse side. 'I p, Signe _ i Title: Date: S"'Z F -1 FDR DEPARTMENT USE ONLY Application Accepted by 01 Date Area Pit or Grout Inspection by Date Final Inspection by�� Date" Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca a23-71134 ❑ 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. +.EH1 -241REV.tiwsf EH 10.28 V / 4