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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. i8u for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name t r Address f ' Phone r i i. iL _ ��4 I Contractor ress _ V -�-- — -L•icense'No- Phone TYPE OF WELL/PUMP: NEW WELI ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAI ��r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGR CULTURE WE OTHER WELL PITS/SUMPS G t INTENDED USE TYPE OF WELL PROBLEM A A C STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom# ❑ Manteca-- -- ia. of Well Excayation Dia. of Well Casing JI ❑ Domestic/Private ❑ Gravel Pack © Tracy Type of Casing Specifications ` r 1 Public1 ❑_Others ». y`'', �❑ Delta Depth of Grout Seal � Type of Grout 11 Irrigation —.-Approx. Depth— I I East' n Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ' F� ' " State Work Do e Well Destruction © Well Diameter Sealing M terial (top 50'1��, L fDepth Filler Materi 118elow 501 { - ,TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR LADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is avaitable'Within 200 feet.I Installation will serve: Residence Commercial Other Number of living units: 5 Number of bedrooms i G Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Dis osal Distance to nearest: Well 00 Foundation Property Line r� i S .� 'Total len th/size UjI LEACHING LINE >❑ No?& Length of lines. 9 FILTER BED -`❑ Distance4to,nearest: Well Foundation Property Line elm SEEPAGE PITS I 1 Depth S Size Number SUMPS ❑ Distance to nearest: Well_!. _ Foundation C0 Property Line e 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 taws, 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." s The applicant r4st call for quired in ctions. Complete drawing on reverse side. Signed X Title: 1 y Date: ~ _.Z / e r FOR DEPARTMENT USE ONLY i Application Accepted byAL,-- Date Area Pit or Grout Inspection by Rate Final I/nspection by f^ fD'at_e, I � ' Additional Comments: "ter �v� � (� �3 E�`�`u` s 1�7 �lt�dl 1tl I I r ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823- 104 ❑ Tracy 5-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f s f FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. CASH INFO (� 3-24-(RM-11H!51 w - ,it) EH 14-28