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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..:.--f-"-�� ISte_- - �D PC A�� City Lot Size Job Address _ _.,, �..�R�s*f4f� � r' Z��+*z�,-�.. �jRi� �v�a t /'- �'gra 7g I Owner "77's Name �6fAddress r Phhone Contractor Address 7777 64-LE"10tircense No. Phone_ TYPEOFWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-0 a Ir 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 O Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E7 Domestic/Private 171 Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 11 Other Cl Delta Depth of Grout Seal Type of Grout r A t I Irrigation —Approx. Depth 1 i Eastern Surface Seal Installed by s' V� 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction [I Wall Diameter Sealing"Material (top 50 '1 ' Depth Filler Material IBalow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (I " REPAIR/ADDITION l i DESTRUCTION l i iNo septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence— Commercial_" Other 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 PKG. TREATMENT PLT. ❑ Method of Disposal - Distance to nearest: Wel4 _ __ Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .6 SEEPAGE PITS I i Depth Size "I" 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 sKill 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, l shall employ persons subject to workman's compensa- tion laws of California." + k The applicant must call for ail required ins ctions.I CompTabllidrawing on reverse side. Signed X Data: " LL� Title: FOR DEPARTMENT USE ONLY Application Accepted by —Date �� Area Pit or Grout Inspection by Date ��Final by ' Date ` Additional Comments:l / ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 1323-7164 ❑ Tracy P 5-6385 Applicant- Return all copies to: Environmental Health Permit/Service1601 E. Hazelton Ave., P.O. ox 2009, Stk., CA 95241 :y a � a FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO C f + EH 13-24 ✓� C 101 EH 14-23 � J r