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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 City_ � Lot Size --j'XPM 0wner's Name ��r i ly Address Phone ` Contractor's Name� �- W Q1ka ?�L-License No. �S I ` Phone S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ S AttCaUlT 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 n�. -�t ►ssk --_�p5p ❑ 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 Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resjdence L-�ommercial_ Other Number of living units: _ Number ol bedrooms Character of soil to a depth of 3 feet: T-),', ,�c� Water table depth SEPTIC TANK lope/Mfg Capacity�L--L1 No. Compartments PKG. TREATMENT PLT. ❑ Method of 1sp al Distance to nearesf." -Well Foundation -Property Line LEACHING LINE ED—No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation roperty Line SEEPAGE PITS ❑ Depth w,Sizeumbe SUMPS stance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ S 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 ce 'ies the followin •"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 la of Californ a.' The applica ust call r all r aired ins cti . C pl to drawing o verse side. r 6 e Signe itle: Date: fQR DEPARTMENT USE ONLY Application Accepts y I Date �� Cy Area 0r or Grout Inspe y Date- Final Inspection b ' _ DateqW Additional Comments: _ ❑ Stk 4664781 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO CASH ` + EH 13-24(REV.10!93) iAs Y � �s SS—1 EH 14-26 * Q=b.p