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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 District. Job Address `� ityLot Size PM I f/ �iil�J.� � � ddress _�, Owner's Name /Y�✓�d � �' _ Phone Contract 71 By ,- Address � � +7 License No. Phon TYPE OF WELLIPUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTIONS❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR`❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL "` OTHER'WEL;"`_"' ' - PITS/SUMPS INTENDED USE TYPE OF WELL' k PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom �,D Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private C] Gravel Pack 0 Tracy Type of Casing Specifications c n F1 Public ;4. 1� Other Fl Delta Depth of Grout Seal Type of Grout J I I Irfigatian I"%_.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 Itop 501"' Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRJADDITIO�& DESTRUCTION I I INo septic system permitted if public sewer is G available within 200 feet.) © Installation will serve: Residence_ Commercial_. Other r Number of living units: 7- Number of bedrooms _s?_.._.,.. ) Character of soil to a depth of 3 feet: '• Water table depth SEPTIC TANK Type/Mfg aCapacity m LNo. Compartments PKG. TREATMENT PJ, ❑ x Method of Dis sal Distance to nearest: Well undation _"_- Property 'ne024 LEACHING LINE 0 No. & Length of lines — Total length/size i QFILTER BED L1 Distance to nearest: Well '- foundation Property Line f� SEEPAGE PITS 11 Depth Size Number SUMPS t Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di%trict. 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 Calif ia." The applicant call f 11 reSpV late drawing on reverse sid . Signed X Title: Date: FOR DEPARTMENT USE ONLYI j Application Accepted by Date 1�` Area Pit or Grout Inspectiq bb / f /Date Final Inspection by � ! Date LJ Additional Comments:T/ �{r `` --Old '�C1z 4�7{ f�fY iZ 471f-V ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82311 ❑ 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 AMOUNT REMITTED CK CASH RECEIVED 6Y DATE PERMIT"NO. INFO r EH 13-24(REV.1 i x 51 EH 14-25 �6�5