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APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ° 11 (Complete in Triplicate) `� �{�ALT� t r' Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work her " Wo ibetl:�T is{�ppCC�bn is q p p �� 1e' aJoamade in compliance with San Joaquin County OrdinanceNo. 549 for sewage or No. 1862 for well/ ump and the Rules an o Joaquin I' Local Health District. Job Address / '"� °� � r'y' City Lot Size PM Name rte` Address ' - Phone/7',7,r- Owner's Contractor:..� <'�� Address t�`-�� License Nol �L�? Phone_ TYPE OF WELL/PUMP: , _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ r OTHER ❑ V DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLD. - PROP. LINE S FOUNDATION,, . __,.. _AGRICULTURE.WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i K Domestic/Private fa Gravel Pack ❑ Tracy Type of Casing ' Specifications F1 Public F Other ! 17 Delta Depth of Grout Sea] ; Type of Grout I I Irrigation --Approx. Depth l I Eastern Surf a Seal Installed by = Repair Work Done 0, Type of Pump H.P. f - State;Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'I 1 y k t Depth Filler Material/Below 50']� 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION 1 I DESTRUCTION I.i.Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-_ Commercial" Other Number of living units: Number of bedrooms x s Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg _Capacity_� No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Well" -Foundatidri4 Property line t LEACHING LINE ❑ No. & Length of lines "' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation "Property Line SEEPAGE PITS i I Depth 1 Size Number .` SUMPS Ll 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: "] certify that in the performance of the work for which this permit is issued, I shall not employ any persorf in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies thwfollowing: "I certify that in the performance of the work for which this permit is issued, Ishall-employ persons subject to workman's compensa- tion laws,of California." ( S l The applicant m call for all re ir'd inspections. Complete drawing on reverse side. I Signed.X - tle: f Date: [~ � w - FOIA DEPARTMENT USE ONLY Application Accepted by Date Area/ — Pit or Grout Inspection by Date Final Inspection by Date fAdditional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant . Return all copies to: E=nvironmental 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 +.EH13-24(REV.r/n5) � - EH U-26