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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � A 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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. tw Job Address 6� Sb citY7 Lot Size PM Owner's Name 1" �~ Address Phone Contractor Address s34) cense No.1LZ3 6 2 Phone TYPE OF WFLL/PUMP: NEW WELL ❑ WELCREPLACEMENT ❑ 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 fl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V-0,omesticIPrivate Ll Gravel Pack ❑ Tracy Type of Casing Specifications M Public I Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation --AAprox, Depth I.l Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump-4ax�& H.P. - State Work Done � Well Destruction ❑ Well Diameter r Sealing Material Itop 501 L �� Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I I- DESTRUCTION I 1 M6 septic system permitted it public sewer is available within 200 feet.) c 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 Capacity No. Cp 1't�f��y PKG. TREATMENT PLT. ❑ MltMo Nisposal ,, Distance to nearest: Well Foundation Property,Lrrle r LEACHING LINE ❑ No. & Length of line_s,- - — -- ---�--— Total length/size FILTER BED ID Distance to nearest: Well Foundation~ P perty Line AEALT {�. d 6t=1MTISEIRVs SEEPAGE PITS I I Depth ' Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done16 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 coma ensation 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." ;F The applicant mu for all r1kqu.ed inspections. Complete drawing n reverse side. Signed X Tit ti Date: L0 X22 ~ f ' 4 { R DEPARTMENT USE ONLY 7 f Application Accepted by ` Date r Area E � Pit or Grout Inspection by Date Final Inspection by ate �� Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I 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 CK RECEIVED BY DATE PERMIT�NO. INFO f_ CASH a �( 'j r.EH13.24(REV.1/x5) �� L/�� r a�� r-17 3 EH 11-241