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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �!� o `"`'O — 'b(3 — City Lot Size PM }-{ 6 Z%�i f2b(5"0 Q b Phone Owner's Name f Address 3 (�obz- 6 Contractor's Name License No. Phone TYPE OF WELL/PUMP: .:.T; NEW WELL ❑ WELL R PLACEMENT ElDESTRUCTION 11s PUMP INSTALLATION IAC 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 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private", ❑-Gravel Pack ElTracy Type of Casing 5 Pecifications Public n D Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation �Jlpprox. Depth ❑ Eastern urfa Seal Installed by Repair Work Done ❑ Type of Pump H•P• - State Work Done3� Well Destruction El W611 Diameter Sealing Material {top 501 f Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is \lv t- available within 200 feet.) Installation will serve: Residence_ Commercial_ Other O 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. ompartments PKG. TREATMENT PLT. ❑ Ms a Method of Disposal _ Distance to nearest: Well Foundation P6operty Line Qr F �ti 4� 4 •y LEACHING LINE ❑ ?No. & Length of lines Tothl length/size I FILTER BED ❑ xDistance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ "Depth Size Number ! „ SUMPS 71'1 Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ -V ' 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 icensed 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 s n in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub signature certifies the f to ing:"I cert{ hat in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of al'ornia." The applicant st call for al req ire i ctions. omplete drawing on r verse side`,r Signed Title: - Date: FOR DEPARTM USE ONLY �� w4 z V:—:- Area Application Accepted by Date .37� ri. F' al-Ins on by Date Pit or Girou4lrispection by _ Date Pe-. Additional Comments: ❑ Stk 466.6781 ElLodi 369-31321 ❑ Manteca 823-710�4� _ ❑ Tracy--$35c6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave.,P.O. Box 2009,Stk.'-CA-9520.1,_, CK 0FEE AMOUNT DUE AMOUNT REMITTED ASHLRECEIVE_D BY DATE PERMIT`NO, INFO p1c'f{i+ EH 13-24IREV.101831 -' � — �� " EH 14-28 � r