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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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address t"P City Lot Size PM � E Owner's Na L I Address k��` ` Phone Contracto - Address �f �� °-License Nv.Lj�=L3 F' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION C7- SYSTEM REPAIR OTHER ❑ .t 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. f Well Casing '(_.Domestic/Private El Gravel Pack ❑ Tracy , . Type of Casing Specifications F1 Public [-I Other FI Delta Depth of Grout Seat Type of Grout 3 I I Irrigation Approx.'Depth I I Eastern Surface Seal Installed by Type of Pump.�� --- H.P: :)=�` State Work Done Repair Work Done DL Typ ttt � Well Destruction ❑ Weil Diameter Sealing Material (top 501 — Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is } available within 200 feet.] N Installation will serve: Residence_ Commercial— Other . yl►q1 , + i Number of living units: Number of bedrooms s t y Character of soil to a depth of 3 feet: Nater table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments{{��pp PKG. TREATMENT PLT. ❑ ,I 1.. MetR�rb91�f 1Jis�siaPa V► I Distance to.nearest: Well Foundation Property Line 17 LEACHING LINE Elth of.lines. 9 No.-&'Len Total length/saeV FILTER BED ❑ Distance to''nearest: Well _ 4 Foundation -" `"" Property Line I SEEPAGE PITS l 1 Depth I Size Number ' SUMPS D 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 i 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 m call for all r inspections. Complete drawing on reverse side. Signe X r� Title.- Date`.-- �— FOR DE RTMENT USE ONLY r Application Accepted by Date Area r Pit or Grout Inspection by Date Final Inspection by Date 6 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 FEE AMOUNT RUE.1 AMOUNT REMITTED CASH CK RECEIVER BY OATS PERMIT NO. INFO +.EH13-24(REV.i/e5) ' I I ^ZZ EH 14-28