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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE.., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y (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.' �H Job Address / City Lot Size PM Owners Name �G Or� Address Phone ` Contractor `� Address License No.5041S_3'5"g' Phone 44R-- 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 t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing r Specifications j LJ Public El Other L1 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 'ty REPAlR7,ADDIT;O ,.DESTRUCTION %INo septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence �✓ Commercial Other- Number of living units:_� Number of bedrooms ± er Character of soil to a depth of 3 feet: *v `�`�''`' ` r ".' 5 Water table depth SEPTIC TANK Type/Mfg cc c Capacity"' l Z� No. Compartments PKG. TREATMENT PLT. ❑ ` ' € "Method of Disposal Distance to nearest:.t• Well / got- Foundation Property Line 4;� _ LEACHING.LINE ❑ Nd. & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation €' Property Line SEEPAGE PITS ❑ Depth ' < Size Number SUMPSf ❑ Distance to nearest: Well ..Foundation Property Line DISPOSAL"PONDS ❑ I hereby certify that I have prepaied 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. i 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 following: "I certify that in the performance ofthe work fog which tFiis permit'is issued, l shall employ persons subject to workman's compensa- tion laws of California." . � , -51 The applicant must ca all quir ins s. Complete drawing on reverse side. r. Signed Title:µ ' c�� Date: FOR DEPARTMENT USE ONLY / �} Application Accepted by / ' r t Date 5 r 7 Area Pit or Grout Inspection by T Date Final Inspection by Date S �� �I Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 _ ❑ Manteca. 823-7104- _ ❑ Tracy,,;,835-SM Applicant"Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24 IREV.I/a 51476 S.--1 -� $ ?. ^"-VL'.- EH W28 11