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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E/ (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AddressY /v ' G� �L [ '� City Lot Size 7 M Owner's Name Addresser/�-(�7/[Q�+r Phone Contractor Address License No. Phone 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Jt Repair Work Done ❑ Type of Pump H.P. State Work Done_ rl Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 4 OL TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (vailable within 200 feet.)septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cape it o. Compartment PKG. TREATMENT PLT. El Method f ' p� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total le FILTER BED ❑ Distance to nearest: Well )Fud ' n r erty Line ,_r)X SEEPAGE PITS ❑ Depth Size h/uv NAperty SUMPS Eli n Distance to nearest: Well FoundatLine DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in a dance 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 i e 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 call for all required inspections. Complete drawing on reverse side. Signed Title: ate: 1 �� r-AOR ENT USE ONLY l Application Accepted byJ ��'' Date `3' Area 03 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED I CKRECEIVEDBY DATE PERMIT'NO. INFO CASH y� "'-+ EH 13-241REV.1/8 51 ��3 _ EH 14-26 `�'%