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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �I 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 N�� t/v t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 41- (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. Job Address cK ` S• 7 City Lot Size PM Owner's Name0 Address Phone =+ r Contractor �1 Address r `O' d�-+ License No.2515 tG0 Phone TYPE OF WELL/PUMP: �, NEW WELL ❑ WELL REPLACEMENT D 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 ice• ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications , ❑ Public ❑ Other ❑ 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 Well Destruction ❑ Well Diameter Sealing Material (top 50'1 l Depth Filler Material (Below 501 # ` TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION L1 DESTRUCTION I No septic system permitted if public sewer is available 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: Water table depth —..SEPTIC,TANK--O'—T /Mf """ —f^_ _ t Yp"e 9 r "Capacity'—" ''" '"""" —No:CompaFfmenTs"""'" PKG. I REATMENT PLT. ❑ Method of Disposal i j Distance to nearest: Well Foundation Property Line ,4 LEACHING LINE ❑. No. & Length of lines Total length/size i *t r. i FILTER BEDS J❑,Distance to nearest: Well Foundation Property Line SEEPAGE PITS �1 )I'1 Depth Size a f _ Number SUMPS f /Distance to nearest•. Well i Foundation Property Line �+ DISPOSAL PONDS ❑ f -s 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 employlany parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifieJ the following: "I rtify, at in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion taws of Californi j The applicant must all U uired inspections. Completed awing on reverse side. i- Signed i r Title: - .., Date: F ' i I FOR EPARTMENT USE ONLY - Application Aeeepted by Date_ 1 — g _�J� Area 1.5 Pit or G1 1:1tlspection by 1 I, Date # Final Inspection by Date l Additro al Comments: .{� j ' ❑ Stk 1466-6781 ❑ Lodi '369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE + AMOUNT DUE AMOUN}TREMi T �ED CK; 1-1 RECEIVED BY DATE PERMIT N D.INFD CASE EH 13.24{REV.r/n 513EH 14-26 _ f HOb