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APPLICATION FOR PERMIT 6� 6/ 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 EJobl Health District. Address �'� / �it? � City Lot Size— _ PM I �a,� / E�jer's Name JDA°"'` � Address 94� ! Phonet. ; tractor Address LicensePhoneE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS _ INTENDED L PROBLEM AR CONSTRUCTION SPECIFICATIONS 41 Industrial ❑ Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type o Specifications (1 Public C1 Other _ F1 Delta Depth of Grout Seal Type of Grout I I Irrigation pprox. Depth ( 1 Eastern . Surface Seal Installed by _ -t Repair Work Done Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION I I DESTRUCTION (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 f ��,•- �tea: LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE-PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation r Property,L-ine DISPOSAL'PONDS ❑ I hereby certify that I have prepared,this,application and that the work will be done-in acc_ordance.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 applicant us all for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 2^^ Area of Pit or Grout Inspection by Date_ sinal Insrection by Date Additional Comments: O :�Ml /`S +� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 7 ❑ 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 CK CASH -RECEIVED BY DATE PERMIT'NO. +.EH 1 -24(REV.1/n 5) s/ � _S `Q� EH/44-28 /// 'I s