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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t F 1601 E. HAZE T ON AVE., STOCKTON, CA 1 Telephone Q091 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 de ribed. This ap /(tali n is made in compliance with San Joaquin Cobnty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f l i Job Address �! �'✓�` Cit at Size �p P j� Owner's Address-2 04�:2' o`- � j j Phone' i Contractor Address License No. 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications J ❑ Public 1_1 Other 1 11 Delta Depth of Grout Seal Type of Grout__ I I Irrigation —Approx. Dep th I 1 Eastern Surface Seal Installed by �A Repair Work Done Ll Type of Pump. H.P. State Work Done Well Destruction ❑ Well Diameter{ Sealing Material (top 50') M Depth 1 Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailahle within 200 feet.► Installation will serve: Residence�} Commercial_ Other \- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest Well Foundation Property Line \ LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to'nearest: Well Foundation Property Line { l SEEPAGE PITS l I Depth t Size Number I SUMPS 0 Distance to7nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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: 1 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 taws of California." The applic ust call for required inspections. Complete drawing on reverse side. y Signed Title: "�� v�y — ?, w \ Date: FO EPARTMENT USE ONLY Application Accepted byDate ^ Area Pit or Grout Inspection by Date Final Inspection by + 1 Additional Comments: ateG � , ❑ Stk 466-6781 ❑ Lodi 369-36214 ❑ Manteca 623-7104 ❑ Tracy 835-6365 f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1< FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE CASH PERMIT NO. a.EH13-24 iltEV.E 426 t