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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 Rules and Regulations of the San Joaquin Local Health District: ,- Job Address a f /� ALJ City Lot Size1�x�� PM Owner's Nam Address S t Phone/ k7 Contractor T- Address" License No. Phone TYPE OF WELL )IOP: _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. ofWell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications 17 Public ❑ Other 1 71 Delta Depth of Grout Seal Type of Grout . I I Irrigation _Approx.�Depth l 1 Eastern i Surface Seal installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done_ Q Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth t� Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 11 DESTRUCTION INo septic system permitted if public sewer is -'available within 200 feet.) Installation will serve: Residence='�-�" Commercial Other O Number of living units: Number of bedrooms Character of soil to a depth of 3 feet{ Water table depth SEPTIC TANK ❑ Type/Mfg, Capacity ` No. Compartments PKG. TREATMENT PLT. ❑ -•-..t Method of Disposal Distance.to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance'to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth J Size Number SUMPS ❑ Distancerto nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 , I hereby certify that I have prepared thi.{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 the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." T'_ pli t must call for all required inspections. Complete drawing on reverse side. ed Title: Date: 1 7 FOR DEPARTMENT USE ONLY Application Accepted by ' S.1\.LJ1L "„ .."_. Date � � Area Pit or Grout Inspection by Date ,Final Inspection by_ Date, Additional Comments: Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantece 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 f FEE INFO AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE P7-1 PERMIT'NO. ' ♦ EH 13-24(REV.tits5k Ks.co L S-/r� P7 P7- 9 EH 14-26 ✓ ^� l