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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 Ham, �� F�( J City jQC110� Lot SizeQ�/-�] .S PM Owner's Name Address � >2J� �� C� Phone Contract Rddes s� � License N Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT % i DESTRUCTION ❑ PUMP INSTALLA IRO SYSTEM RVAIR ❑ OTHER El _ © �r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Cj�0 '' DISPOSAL FLD. PROP. LINE . 5_ 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 S776:A Specifications f°l Public ❑ Other ❑ Delta Depth of Grout Seal t—ID — Type of Grout I I Irrigation _.Approx. Deptrh1f�I I Eastern Surf ce Seal Installed by Repair Work Done y Type of Pump IU?J22. H.P. �� '� State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is �� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line `vJ v SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 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 compensa- tion laws of California." The applican s ca for all required inspections. Complete drawing on reverse side. +n� y, h Signed X Title: �� ,�/ �� Date: /2Z tai Ol� OC FOR DEPARTMENT USE ONLY Application Accepted by 1CM V ____ Date��— 12—":Area � _ Pit or Grout Inspection bgNiz Date _ Final Inspection by /Z loo Date /!/moi Additional Comments: e� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M&Kteca 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 INFO AMOUNT DUE AMOUNT REMITTED CASH / /CK 4 RECEEIIVED BY DATE y � PERMIT'NO. +.EH 13-24(REV.I/H 5) s / / 1,2 �? EH 14-28Q f2 <V G�