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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 A 2o 0455 < Lot Size IJy� PM �-�j Owner's Name ,�-r S i p�S Address 75 A #167 Phone4j(,2 6a O 0 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERE-0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINEST "' DISP PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS III INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ M Dia. of 1+Vell Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack Tracy Type of Casing Specifications �! M Public n Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Dan Type of Pump H.P. State Work Done Well pe tion ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 R£PAIRIADDITION,.I 1_ .DESTRUCTION (No septic system permitted if public sewer is I available within 200 feed Installation will serve: Residence_ Commercial T Other F Number of living units: Number of bedrooms i 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 D FILTER BED ❑ Distance to nearest: Well Foundation Property Linel SEEPAGE PITS ( I Depth f Size Number SUMPS 0 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."Contractors 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 Cali ia." The a plica call 1pr all requir ins ns- omplete dr wing on reverse side. Signa Title: Date t " FOR DEPARTMENT USE ONLY A plication Accepted by r Date 7— 7- Y2 .Area v Pit or Grout Inspection by Date Final Inspection by Date [ . Additional Comments: �`� {-�`�� -L�►^ ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca E[23-71CV ❑ Tracy 835-6385 p Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 li M FEE INFO AMOUNT DUE AMOUNT REMITTED) CK RECEIVEDBYDATE �7 PERMIT NO. + EH13.24(REV.i/x5) EH 14-26 i