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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 Coun Ordinance No.549 for sewage or No. 18V for well/pump and the Rules and Regulations of the San Joaquin Local Health District. St0©� Job Address J_G ate_ PaG�l� ��`-a9�IIn ___-- _-- City Lot Size PM Owner's Named © t Address Phone Contractor—\�u,�.6i Li 55-1k�SG AddressZ8Z_";67 S License No.4_47-52— Phone 9W-134-5 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 + ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of GroutC�'t ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 1 Y�eGc45 + Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l /+ 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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."Contractors 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 or ia." The applic t m s c II ora I quired inspections. Complete drawin on rev a side. Signed Title: 01 Date: i3 S F A T USE ONLY Application Accepted b / Date �� r a // 3- Pit or Grout Inspec y Date "' Final Inspection by Date s Additional Commentq ❑ Stk 466-6781 ❑ Lodi 369 ❑ Mante 823-7104 ❑ Tr,4,Zy 835-5385 � Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.0 Stk., CA 95201 FEF INFO AMOUNT DUE AMOUNT REMITTED i K* RECEIVED BY DATE PERMIT"NO. +EH 124 1REV.1/s 5) EH 1126