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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT `-� 1601 E. HAZELTON AVE.,,STOCKTON, CA Y( "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. �p Job Address ` /Z � � j city Lot Size PM Owner's Name 'ter{� T� � Address -7 ��` � Phone Contractor �- '`'�� Address #400-a' S,j jf�' License No. �71*e Phone �}01C ^? ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �\ INTENDED USE TYPE WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 'f❑'Open 0otto.rn ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel`Paq( ❑_Tracy Type of Casing Specifications ❑ Public ❑ Other `' ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _L4pptox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diargeter Sealing Material (top 501 DepthMaterial (Below 501 TYPE OF SEPTIC WORK: NEW IN TALLATION ❑ EPAIR/ DITION DESTRUCTION ❑ (No septic system permitted if public sewer is 3 " available within 200 feet.) Installation will serve: Residence ` Commercial_ Other Number of Jiving units:-I— Number of rooms Character of soil to a depth of 3 fget: �F Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ µ Method of Disposal DlsteJ�tc*'tanearest- Well Foundation Property Line , LEACHING LINE A� No. & Length of lines 40 -0401, Total length/size FILTER BED ❑ .Distance to nearest: Well Foundation 2� Property Line SEEPAGE PITS 4r—Depth 2� Size l 'd Number SUMPS ❑ Distance to nearest: Well VV Foundation _ Property Line DISPOSAL PONDS ❑ 1 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,Igws of California."Contractor's hiring or sub-contracting signature certifies the following:"1 ce 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 c uire . Complete drawing on reverse side. Sianed X Title: S0 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date l" 3- '`Area Pit or Grout Inspection by Date Final Inspection by Date Addit-Inal Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835MM Applicant- Return ah copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2008, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH REC&VEO BY. DATE PERMIT`NO. + EH13-24(REV.t/t35> �+�. Li EH 14-28 O • v /96 b b�1