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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 he+eby 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 'e'er City eAmP& Lot Size � + � PM Owner's Name Address it - OPh e Contractor Adtlress icense iVrr�--Cf�g3 Phone � -�f'� �A TYPE OF WELL/PUMP: NE WELL . WELL REPLACEMENT ❑ DESTRUCTION G PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Elf i DISTANCE TO NEAREST: SEPTIC TANK "Vlt— SEWER LINES DISPOSAL FLD. PROP. LINE roc v FOUNDATION AGRICULTURE WELL OTHER WELL 1°tc7k 1C PITS/SUMPS i- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial 'Open Bottom ❑ Manteca Dia. of-Well Excavation Dia. of Well Casing ' 'Casing—_--e�� S �v_ ® y omestic/Private --❑ G►avel Pack" ❑ Tracy— " Type of - pecifications----------^ f 1 Public F Other F1 Delta Depth of Grout Sea] � Tyne Greut�j"Got `/} I I Irrigation ��..Approx. Depth I(1 Eastern Surface Seal Installed by ~ - V 1 Repair Work Done ❑ Type-of-Pump. ' H,P. State Work Done Well Destruction ❑ Well Diameter `; Sealing Material (top 501 It Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1'1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is -- j available within 200 feet.) Y Installation will serve: Residence____ Commercial— Other r Number of living units: Number of bedrooms * �r 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 ' o 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 I SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 'certifies the fottowing: "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 for all required inspections. Complete drawing on reverse side. 'SignedX- a`I{=7i�t�/7 Titter _. 2 --Date'. x FOR DEPARTMENT USE ONLY _ Application Accepted by =Date Area 1'a. Pit or ro nspection by Date - Final Inspection by Date 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 DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH I 1�� PlR- f 19 +.E11 13-211gEV "r` EH 11-28