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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 / ^` �' �� Y I � ' City Y Lot Size PM Owner's Name ^ Address 1 t`-`^` Phone `�/ > t Contract Addresskr_), � /IIL� C ",License No�2�126 Phone, f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- I rout _I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Material (top 501 v 1 Depthaterial (Belo 50') M TYPE OF SEPTIC WORK: NEW INSTALL. TION I l REPAIR DDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: —/— Number of be rooms Character of soil to a depth of 3 feet: Water table depth J a SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line b ! ! f LEACHING LINE >( No. & Length of lined 70 T9tal length/size x FILTER BED ❑ Distance to nearest: Well Foundation 14 Property Line i 1 SEEPAGE PITS 1 I Depth Aa Size X Number P SUMPS X Distance to nearest: Well=QA Foundation—_/40_ Property Line 3— 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 Di§trict. 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." The applicant must car all req '7e!4iections. Complete drawing on reversid .Signed X sTitle: Date: FOR DEPARTMENT USE ONLY Applicatio ccepted by` Date 3i4 49 Area Z Z Piro r Ins�i�n'by �T/ %�Date �f � *�f Final Inspection by� ate Additional Comments: G ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEJ AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO �.EH13.24 1REV.1/N al �� 0 EH 14-26 VVV