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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES A YEAR FROM DATE ISSUED k)ou (Corrlplete 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. a Job Address y�" 'z I/ ' City Lot Size PM Owner's Name .616+11111k. Address a�aa�az Phone C, Contractor AAIL � Address r ,r` License No:Y 9Il® Phone 9�W_0;ff TYPE OF WELL/PUMP: :'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ T SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD. LINE { FOUNDATION AGRICULTURE WELL OT HE PITS/SUMPS INTENDED USE TYPE OF WELL"'PROBLEM AREA—CO N VSPECIFI'CAT10NS'�T-�-; ❑ Industrial L) Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private IO Gravel Pack Tracy - Type of Casing specifications �. ('l Public Ll ❑ Delta Depth of Grout Seal Type of Grout a I I irrigation Approx.-Depth { I Eastern- Surface Seal Installed by _ Repair Work Done - ❑ Type of Pump, H.P. State Work Done Well Destruction ❑ Well Diameter: - 3,tSealing.Material (top 501 Depth Filltei`Material-(Below 50') i TYPE OF SEPTIC WORK: -NEW INSTALLATION 1.1 REPAIR/ADDITION 1,11 DESTRUCTIOINo septic system permitted if public sewer is I I s available within 200 feet.) 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 �. Type/Mfg Capacity No. Compartments PKG. TREATMENT'f'LT_❑ ,, Method of rDisposal f Distance to nearest: Well YFoundaiior Property Line ! py i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ .Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS_ 11 Depth Size SUMPS Ll 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.. 5 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, l 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: "1 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." r 2 The applicant t call-for all required iinns�ctions. Complete drawing on reverse si e. s ' • laov F 7Signed e or IFIDEPARTMENT USE ONLY Application Accepted by ��:.� Qom*..` '*`jg. Date,5 Area Pit or Grout Inspection by Date Final Inspection by +" Date L_01 Additional Comments: I ❑ 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 - i CK 4 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERM17'NO. j + EH1324[REV.1iH5) � - EH 14-29