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w 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 , q (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereirph�-s pplication 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 `� CitysAt& Lot Size G Uf/d o PM Owner's Name AddressZ�-- Phone Contractor I ddre 1/ /r _ _ License No Sit Q. Phone! 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing ❑ Domestic/Private ❑ Grevel Pack ❑ Tracy Type of Casing Specifications i"1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 13 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 I 1 REPAIR/ADD( ON I 1 ESTRUCTI N I 1 I o septic system permitted if public sewer is y�/ ailable within 200 f Installation will serve: Residence_ Commercial_ Other ee I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK : , ❑ Type/Mfg Capacity No. Compartments \t PKG. TREATMENT PLT. ❑ v Method of Disposal `L{� 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 ' SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ 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 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." t t t The applicant must call for equired ins ctions. Complete drawing on reverse side. Signed X Title: Date: �-r3 �PARTM�ENTSE ONLYApplication Accepted by ___( "'� ._ Date Area i Pit or Grout Inspection by Final Inspection by Date "QPIP* / Additional Comments: �/_ 104?ly i / Y/lJ i ❑ Stk 466-6781 It Lodi 369-3621 Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to :Environmental fiealtl Permit/Services-1601 E. Hezefton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.tiw5) S .(� J --�� c.�� ��/3��,p' EH 14-26 Lam` 1✓