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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 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 Distrito. Job Address �0 s ,� Ci A. Lot Size 6¢ xl Zo PM yy p r [ Owner's Name �� Address --JI-242 Sgyw // Phone Z Contractor's Name `�License No. � ?` I? Phone 02- { TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ( A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ D6mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q,Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation -L—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLPyTION El 'REPAIR/ADDITION DESTRUCTION EI (No septic system permitted if public sewer is e// . ;'ov" available within 200 feet.) Installation will serve: Residence_ Commercial—1%�Other Number of living units: ._ Number-of bedrooms n2 Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Zi Capacity_J No. Compartments PKd. TREATMENT PLT. Q ofMethod of D1spWI Distance to nearest: Well #V 0 Foundation Property Line 2 0 f LEACHING LINE ❑ No. & Length lin Total length/size FILTER BED El Distance to es Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to ne s ' I 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 subcontracting 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." r g The applica must call r all required inspections. Complete drawing on reverse side. 6 Signed Title: bate: 12 FPR DEPARTMENT USE ONLY Application Accepted Date "(G Area A�1 Y Pit or Grout Inspecti DateFinal InspectionDate f Additional Comments: 1 ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY i DATEpdy rPEERMIT`NO. r + EH 13-24(REV.10183) EH 13-28 t!t Q� V i�1-`1i / '•ssI