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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 Addressf0 • l!, , .City Lot Size PM Owner's Name Address Phone Contractor �uw 6&' Address / T License No. Phone 6� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 ^rs ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'l Public 171 Other C] Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation ___Approx. Depth I ) Eastern • Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Hone Well Destruction ❑ Well Diameter _-Sealing Material (top 50') 11 ~ v Depth f=iller Material (Below 56, TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITiO_N.l-.)—:DESTRUCTIO 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.'s Water table depth SEPTIC TANK, ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance fo nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ' s � E FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth 3 Size Number SUMPS LI Distance to nearest: Well Foundation - Property Line s DISPOSAL PONDS ❑ r . I hereby certify that I have prepared this application and that the work wiil be done in accord;Pit •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:g g g: "I certify that in the performance of the work for which this permit is issued, I steal] riot employ any person in such manner as to became 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 i r a." The applican for all required inspections. Complete drawing on-.reverse side: Signed X Title: Date: Fft DEPARTMENT USE ONLY Application Accepted by Date �' `" Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ✓ jg ❑ Stk 466-6781 If Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy- 835-63855 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 CK If RECEIVED 6Y DATE PERMIT NO. I r.EH14-24 1REV.1/H 5} ` EH 10-28 � �! L7 7-,x7U �fJl V ff G- J