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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.—JON AVE., STOCKTON, CA Telephone (209) 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. Job Address �-- �� 4�� City Lot Size PM Owner's Name �VII� x" ��+ddress Phone Contractor //Dg /y 5 ddressLicense No? z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION�� PUMP INSTALLATION ❑ �_SYSTEM REPAIR ❑ OTHER Q_ 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 Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SpecifiLations El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation _--Approx. Depth ❑ Eastern ? Surface Seal Installed by Repair Work Done 11 Type of Pump _.� H'.P. State Work Done Well Destruction I)v Well Diameter Sealing Material (top 501 &9.V Depth Fiber Material (Below 50'} C'- T.E\ -' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms l Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ` . No. par7ttmentJs PKG. TREATMENT PLT. L1 �t Met o f dig alp Distance to nearest: Well Foundation t ' Property Line LEACHING LINE ; ❑ No. & Length of lines �! Total length/size FILTER BED ❑ Distance to nearest: WellFo ndation Property Line,: ' -47— _,1, i SEEPAGE PITS j ❑ Depth Size_ Number ; SUMPS ❑ Distance to-nearest: , Well }S Foundation Property Line DISPOSAL PONDS fl 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 bf the San Joaquin Local Health District. s 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." 1 The applicant m uire s. Complete drawing on revirse yitle. 1I1 p Signed Title: [/// 4/ Date{ a I t n FOR DEPARTMENT USE ONLY Application Accepted'by �' ` Date "� Area 7 Date Final Inspection by I Date Pit or Grout Inspection by , i Additional Comments: a ❑ Stk 466-6781 I ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all`copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9501 i t FEE i AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE j PERMIT'NO. INFO + EH13-24 IREV.1/e 51 r. �. ,f �`�► `I�q 3 EH 14-28 - - - --- i