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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 (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 /fT� � —J-7 &9ja Lot Size PM Owner's Nan,4,� �� - Address 4, 00P , Phone Contract _!�-- Addre License Pho TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1:1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRlRE WELL - OTHER WELL' PITS/SUMPS INTENDED USE TYPE OF WELL P EM AREA CONSTRUCTION SPECIFICATIONS R ❑ Industrial ❑ Open Botto ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Graved ck ❑ Tracy Type of Casing Specifications ('1 Public her ❑ Delta Depth of Grout Seal Type of Grout G, I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by 1 _ Repair Work Do ❑ Type of Pump H.`P:e= State Work Done_ Well Destr on ❑ Well Diameter Sealing Material (top 501 " d Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1.1 DESTRUCTIO '(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. ❑ t 1 F Method of Disposal Distance to nearest: Well Foundation Property Line l LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 3 t SEEPAGE PITS I I Depth Size _ Number' SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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. i 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." i i The applicant ust call for all req `ed ins ctions. Complete drawing on r rse side: Signed Title: Date: -R DEPARTMENT USEONLY p Application Accepted by C ��.4»✓\Grv.�/ Date �C)_ Area Pit or Grout Inspection by ,j�Date `Final Inspection by Date /��p, pry i Additional Comments: No El Stk 466-6781 ❑ Lodi A9-3621 ❑ 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED K C#SH RECEIVED BY DATE PERmrr'NO. ♦ EH -(REV.1/H 5) 3�-__ /-03 1`-a y-�� --3Qg3 EH 14-28