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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Sahi 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. 11 ! Job Address .S City Lot Size PM f it t p�� L� !` �/ _` Owner's Name SdFess 7 7'5 7�-_ Phone / 1 .i. ContractorvL Address License No. Phone TYPE OF WELL/PUMP: 11 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O ii DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE rt FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I�TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G� ❑ Industrial _ d Open-Bottom ❑ Manteca . Dia- of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications _ q 1-1 Public 0 Other Delta Depth of Grout Seal Type of Grout \lV\ C 1 I I Irrigation - L_Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RE-PAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is I --available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms :,I j Character of soil to a depth of 3 feet: Water table depth l SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well f=oundation Prooerty.Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑I Distance to nearest: Well Foundation Property Line e SEEPAGE PITS i I Depth Size Number I. SUMPS FI 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 Disttict. 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 suchmanner 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. IN F The applicant mu c I for all required i9spWrons. Complete drawing on reverse side igned X Title: [,(�/�/ Date: f FO DEPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout Inspection by I` Date Final Inspection by Data Additional Comments: Z, ❑ Stk 466-6761 ❑ Lodi 364-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE /PERMIT NO. +.-EH 13-21 tREV.11K 51 � � EH 11-2e