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�(O APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 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 1.35 otf1-t C- Lot Size PM `gg -7� 7t6 Owner's Nam Address 1 7� Phone c. Contract C Address ,7(o � License No. 2 X2-4-Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT. ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications "4 M Public Fi Other f]Delta Depth of Grout Seal Type of Grout's :I f Irrigation �.-Approx. Depth I i Eastern Surface Seal Installed by W 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITIODESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence A Commercial— Other Number of living units: --�__ Number of bedrooms 3.-- y Character of soil to a depth of 3 feet: Water table depth y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. &'Len th of lines i f g j "' �� f- Total length/size X FILTER BED ❑ Distance to nearest: Well I a a Foundation ✓I Property Line "r i SEEPAGE PITS IA"'-Depth ^ Sizes-- Number SUMPS L� Distance to nearest, Well d Foundation r a< F3 Property Line DISPOSAL PONDS i ElI 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 I rules and regulations of the San Joaquin Local Health District. * Nome 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 i 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 tion laws of California." l The applicant m call for all require ' pections. Complete drawing on reverse side. J Signed X Title: Date: FID DEPARTMENT USE ONLY Application Accepted by . Date — Area r Grout Inspection by pate Final Inspection b Data Additional Comments: . ❑ Stk 466-6781 ❑ 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 "FEE AMOUNT DUE AMOUNT REMITTEb CK RECEfVEO BY DATE PERMIT NO. INFO CASH +.EH 13-24(REV.1/n 5) �. �v7�0 EH 14-28 11