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APPLICATION FOR PERMIT 5,tz SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 1466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. Job Addressr22 03 Citti y 5 f i a�'I mit–Lot Size �r •L'© �M Owner's Name –nY. /?i/JVIE m'A- a - Address _ /V1XAfSW r,;E Phone 14 Z Contractor Gh Address �/[� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C1 " 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 } M Public f7 Other I❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done i ` I Well Destruction El Well Diameter Sealing Material (top 501 Depth Fiber Material !Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial— Other d Number of living units: Number of bedrooms V"v_ Character of soil to a depth of 3 feet: 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: Well Foundation Property Line n . Y SEEPAGE PITS I I Depth Size Number SUMPS Cl -Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 Di1trict. 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 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." ' f The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: %J,� FOR DEPARTMENT USE ONLY Application Accepted by Date y 1� '- 7s U .grea T"• Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6385 Applicant - Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK % INFO CASH RECEIVED BY DATE PERMIT'NO. 1 I + EH 1 n -241REV.r/ 51 �� 2 ��rdy EH 1f4-2 0- 4 4/ 1 �N7