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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 District. ;7 Job Address _gn4 % % 71W / �`� �,!� City Z� Lot Size PM Owner's Name r� N Address 24 �� ! � "��- 1 Phone f. n � Contractor's Name , •��Z�GL1� License No. Phone � � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION :❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER '❑ DISTANCE TO Ni4REST: SEPTIC TANK '* SEWER,LINES-:-_ DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ",TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ❑ Open.Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing El Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications - + ❑ Public? ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ,.❑ Eastern Surface Seal Installed by Repair Work Done O---Type•of-Pump- "H.P. x State Work Done i Well Destruction ❑ Well Diameter Sealing Material.{top 50'). i fDepth Filler Material {Below 501 �s ! TYPE OF,SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0ESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) J. Installation will serve: Residence - Commercial_ Other Number of living units: _L_ Number of bedrooms Character of soil to a depth of 3 feet: j Water table depth ' —._ -. . m--�--K SEPTIC TANK Type/Mfg •� + • ." T "T-Capacity; "No. Compartments PKG. TREATMENT PLT. ❑ �' , �' Method of Disposal Distance to nearest: Well Foundation /4,6 Property Line b LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well . --rFoundatioff- <Property Line's rt SEEPAGE PITS ❑ Depth Size 1 ice_Number' t 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."Contractors 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 tail for II required inspections. Complete drawing on reverse side. T I Signed X Title:,,_ Date: : FOR DEPARTMENT USE ONLY Application Accepted by -1 (1.,, Date Area b 7 'i Pit or Grout Inspection.by Date Final Inspection by 1RA . &au"te Z Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK ' "" 'INFOFEE E__AMT.OUNDUE AMOUNT REMITTED. = CASH' '-�RECEIVED.BY._ __DAT.E__ PERMIT''NO+ EH 13-24(REV,10783E •_ O C', 41A EH W26 1