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APPLICATION FOR PERMIT �} SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephorie (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 District. �y e / �,'4' Job Address �[ .C� City r44 Lot Size- ,, 7,4; � _ PM Owner's Name r' I tri i Address 7 / GS C phone ,5_ ` Z-7 3 31 Contractor ( I�O�l Address7 1141& /tet License No.�3�1-Phone �d7 /TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN/ 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 ExcavationI Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack F1 Tracy Type of Casing Specifications k M Public I.1 Other F] Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by \ Repair Work Done ❑ Type of Pump H.P. State Work Done W Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res i ence ;Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIG,TANK ❑ Type/Mfg Capacity No. Compartments �- PKG. TREATMENT PLT. ❑ 1 _ Method of Disposal Distance to nearest: Well ..,_ _ FoundationProperty.Line �i D 01 LEACHING LINE No. & Length of lines _Total length/size Q FILTER BED ❑ Distance to nearest: ell Foundation lS f Property Line SEEPAGE PITS ( I Depth Size_fL�_ _ 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 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." The applicant must c II for ail require spections. plate drawing on reverse side. Signed X Title: k f Date: FOR'DEPARTMENT USE ONLY r� Appli tion Accepted by A Dale o Area r rout n pection by, Date��._ Final Inspection by ewgy=e Da- Additional Comments: ❑ Stk 466-6781 ❑ 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 AMOUNT DUE AMO�INT REMITTED ;CAH INFO RECEIVES)BY DATE PERMIT'NO. 14- �`� EH 13+24 alt F�1Ai 1 EH 1426 t