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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address _ / ; 0 L'i !/' City 100" J Lot Size PM Owner's Name , S Address Z D`7 Phone Contractor a Address License No. S�M Phone 154 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 Casirlg ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal.lnstalled by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r, Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION7 DESTRUCTIONS❑ (No septic system permitted if public sewer is available within-200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg L' Capacity_ No. Compartments PKG. TREATMENT PLT. -- fj Method of Disposal Distance to nearest: Well Foundation �� Property LiIhe LEACHING LINE ,lrK N0. & Length of lines Tot Ilength/size 1� FILTER BED Distance to nearest: Well, _ Foundation Property Line SEEPAGE PITS !!!❑"` 'Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q 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, ander 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 shal 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 must call 73r required inspections. Complete drawing on reverse side. Signed �-! _ r Title:—o�,.�P_C�-� Date: FOR DEPARTMENT USE ONLY Application Accepted by ` Date Area Pit or Grout Inspection by F Date Final Inspection by Date Additional Comments: ❑ Stic:;:466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental'Health P6rmit/Services 1601 E. H461ton Ave., P.O. Box 2009, Stk.;CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE', PERMIT"NO. INFO CASH In + EH 13-24(REV.1/a 5) 1/ [i?k. )N 4*S EH 14-