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APPLICATION FOR PERMITy 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) l 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 12/1Y)^YlJ l Cityt Lot Size / 61 43 b PM Owner's Name n \ Address / G °� ` � Phone q r,2 Contractor .lJ Address License No. Phone_ TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-E] 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 ElIndustrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing p` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public n Other F1 Delta Depth of Grout Seal `Type of Grout I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _r Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I 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 r Character of soil to a depth of 3 feet: Water table depth I 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 r FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS f I Depth Size Number I SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I 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 4 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 i spections. Complete drawing on reverse side.. �( Signed Xr (�-�Y— ®'>'Yu _ Title: �s%fn� Date: FOR DEPARTMENT USE ONLY Application Accepted by ! Date ArAa Pit or Grout,Inspection by Date Final Inspection b Date Additional Commentst� C �.esLL" .�� r ❑ Stk 466-6781 ' O 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 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24(REV.1 i n 5) A EH 14-2e �'' C'�