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APPLICATION FOR PERMIT 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} f Application is heieby 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 k 0 t City Lot Size�� _ pM Owner's Name ,71 G-2hC _ Address Phone ContractGt�4f z oma+ Address ��/ 7 ' License No. ;X0 PhoO Q 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 3 i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ I f 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 i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 [ w� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION'❑ INo septic system permitted if.public sewer is - �w available within 200 feet.) { Installation will serve: Residence_ ,Commercial— Other Number of living units:7��--Numberof ' r oms 4Cliaracter of sail to a depth of 3 feet.:- _• r • . � '� f Water table depth SEPTIC TANK., t, [S vfww/.Nlfg- -CCo_o No- Compartr ants PKG. TREATMENT PLT-. ❑ • ��-rte. . Method of Disposal Distance to nearest Well( Foundation �(� - Property Line LEACHING LINE �r-iVo-&-kength�of lines +�� ., i Total length/size FILTER BED ❑ Distance to nearest: Well_!� Foundation - 0 Property Line C SEEPAGE PITS B-�&pth �1? _ Size t3 . Number �. SUMPS ❑, Distance to nearest: Well-/dD Foundation Property Line DISPOSAL PONDS ❑ f eZN I hereby certify that I have prepared this application aAd 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. : 4 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 m to for al ui d inspections. Complete drawing on revs a side. F Signed X Title: Date: FOR DEPARTMENT USE ONLY j Application Accepted by Data 6/ tArea Pit or Grout Inspection by. Date Final Inspection byDate 6 Additional Comments: 9� { ❑ 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 f - FEE `s INFO AMOUNT �fD�UE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH13-24(REV.-I,/as) 47 EH 1426 Y