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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Job Address _ !fes f r �0 3 � Ciry ) Lot Size PM Owner's NameAddress Phone Contrac �1 r--t tor " "Z" dress� License No �! Phone ALJ 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 C1 Manteca Dia- of Well Excavation Dia. of Well Casing Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by 111 1 Repair Work pone ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth / Filler Material l6elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIFOADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is Rs / available within 200 feet.) Installation will serve: Residence-1-- Commercial_ Other Number of diving units: Number of bedrooms_, t rk Character of soil to.a dep h of 3 feet: Water table depth SEPTIC TANK ❑' Type/Mfg _ Capa1_1�� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal n Distance to nearest: Well ri Foundation Property Line C3 -- LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well / - Foundation /2 Property Line SEEPAGE PITS I 1 Depth W Size_r Number SUMPS LDistance to nearest: Well Foundation Property Line -i DISPOSAL PONDS ❑ -�N 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 Di"strict. 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." � k The applican7s..call.4 r II rect ired ins ctions. C��t drawing on reverse side. f � Signed X Title: Date: " I FOR DEPARTMENT USE ONLY Application Accepted by q Date rL Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK if INFO RECEIVED BY DATE PERMIT NO. GASH + EH 13-24 tREV.i i k s) 7 ' /�D �' (f