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APPLICATION FbR 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ! Q �l6City Lot Size PM c. r Owner's Nam�I� Address 4__ �..�. � Phone j Contractor L �� L Address c cz's �,�C_ License No. Phone'- f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I�I PUMP INSTALLATION ❑ SYSTEM REPAIROTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I 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 Weil Casing' V 1 )(Domestic/Private ❑ Gravel Pack ' ❑ Tracy Type of Casing Specifications ^111 ❑ Publics i ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump C,0, H.P. —J ____ _ State Work Done -' Well Destruction ❑ Well Diameter Sealing Material (top 501 _ IDepth Filler Material (Below 50') 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 � Ih Number of living units: Number of bedrooms I Characteroff soil to a depth of-3 feeth:' F Water table depth SEPTIC TANK, —0_. Type/Mfg} - "" Capacity No. Compartments PKG. TREATIn1ENT PLT. ❑ Method of Disposal I�. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines r = Total length/size r FILTER BED i� [_1Distance to nearest: Well f. Foundation Property Line SEEPAGE PITS ❑ DeptFi' Size Number SUMPS ,� iy ❑ Distance to nearest:. Wel! 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 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 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 cam nsa- tion laws of California." The ap I' us call for all requ' inspect' s. Com a drawing on r rse side. Signed Title: i`r Date: S R DEPARTMENT USE ONLY y S Application Accepted by Date Area Pit orroutInspection by Date Final Inspection by Date Zt— Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Re turn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO CK f FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. EH13-24[REV. 1 �,{� _ '^7 �L EH 14-28 \/Y f. llI