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APPLICATION FOR PERMIT g SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 02,3 *0-2,61 E_91.4 1P=O Cit ? �7f—C of Size 13 �'— PM Owner's Name Address Zz� 1AD - Phone r Contractor LG- Address z do License No. Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ a SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f L7 Industrial ❑ Open Bottom :.*,} ❑ Manteca _Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ GravelPack ❑ Tracy ._Type;of Casing Specifications FI Public n Offier E-] DeltaDepth of Grout Seal Type of Grout--- I rout _I I Irrigation —..Approx, Depth I I Eastern Surface Scial installed by Repair Work Done ❑ Type of Pump H.P. R State Work Done_ Well Destruction ❑ Well Diameter ,Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION DESTRUCTION ( i (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_t�_ Commercial_ Other Number of living units: Number of bedrooms g. - Character of soil to a depth of 3 feet: _i-; AAk T Water table depth SEPTIC TANK ' ❑ Type/Mfg Capacity-J NaECompartments A. PKG.,TREATMENT PLT. ❑ Method of Disposal ti Distance to nearest: Well� Foundation Property Line LEACHING LINE No. & Length of lines Total lengtW-size-<. FILTER BED ❑ Distance to nearest: Well _JrA0 El_Foundation Property Line��__ SEEPAGE PITS 11 Depth Sizr, Number SUMPS i._l Distance to nearest: Well Foundation Property.Line�* 1 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." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of Me 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 rwired inspections. Complete drawing on reverse side. Signed X Title: "'„'�f — �' Data: F DEPARTMENT USE ONLY Application Accepted by Date r Area Pit or Grout Inspection by Date Final Inspection by Date 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 T FEE''. CK — INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EH13-24(REV.i/n 5) EH 14.26 C>p