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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 Addressv City Lot Size Z PM n� Owner's Name dress Phone I /J Contractor f. dress License No. . Phone U TYP WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTn DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEP SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o Excavation Dia. of Well Casing ! ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ___—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system- permitted if public sewer is y// -`available-within 200 feet.) J ' / � F Installation will serve: ,Residence— Commercial_ Other Number of living units:J__ Number of bedrooms Character of soil to'a depth of 3 feet: "` ` - "Water table depth SEPTIC TANK ❑ Type/Mfg capacity- No.No. Compartments fPKG. TREATMENT PLT. ❑ - r U Method of Dispos ' Distance to nearest: Well Foundation Property Line ._.— ! LEACHING LINE --PrNo. &'Length of lines V= y' Total length/size FILTER BED ❑ pistance to nearest: Well Foundation Property Line SEEPAGE PITS epth Size Number SUMPS ❑ Distance to nearest: Well 12 Foundation 117 d Property Line-44 — 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issuedr I shall not 1 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." L The applicant m st ca for all required inspections. Comple drawing on reyer;e side. Signed Title: - EX 1--( �-�'- Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date Area D it for rout Inspection by a�Date �_1J Final Inspection by � v ateop 6 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy M--&5 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 11 RECEIVED BY DATE PERMIT NO. INFO CASH 10 + EH 13.24(REV.i/6zo �5 EH 14-28