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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 112091 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. w Job Address Q t City �3 7'� Lot Size � � PM Owner's Name �ryAddress � '�'�r Phone !'��`� 9U0 - Gy53 Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION'❑ "` w 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 r}w! ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Lb ❑ Public ❑ Other ❑ Delta Depth of Grout.Seal type of Grout 0 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. t l! State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 94f; DepthAn],2 Filler Matkal (Below 501 C g—_�4 f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 2XESTRUCTION o septic system permitted if public sewer is 4 available within 200 feet.) Installation will serve: Resi %nce_ Commercial her A �Number of living unit�dth Number of bedroomCharacter of soil toafeet: .Water table depth }� SEPTIC TANK Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines } Total length/size FILTER BED ❑ Distance to nearest: Weil_ rFoundation Property Line SEEPAGE PITS ❑ Depth Size Number ' SUMPS ❑ Distance to nearest: Well 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 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."Contractor's hiring or sub-contracting signature certif les 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 for all required inspections. Complete drawing on reverse side. Signed XGQ Title: - - _ Date: FOR DEP(ARTMENT USE ONLY Application Accepted by Date A0 r 3-S Area Pit or Grout Inspection by Date Final Inspection by "tC2 Date Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6365 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 /CASH + EH13-24(REV.10193E p®1 ' /Q, •� �C„ti�_,.' EH 14-29