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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 's°' 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 2 x,., . I / `f•' 3 Job Address /4311 + Cit - `- _f / Y Lot Size / PM y� Owner's Name Address ��d �` �� Phone '7 Contractori Address License No. Phone 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing T Specifications (� i`l Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation - --L-7--,Approx. Depth .1 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top SO') Depth Filler Material (Below 501) I TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTIO (No septic system permitted it public sewer is -available within 200 feet.} Installation will serve: Residence Commercial_� Other y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg! Capacity—!— No. Compartments PKG. TREATMENT PLT. ❑ Method of pisposal r _ a -Distance to nearest: Well Foundation Property Line 4 LEACHING LINE' ❑ No & Length of lines Total length/size FILTER BED ': ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS I 1 Depth I Size R Number SUMPS -'Ll!-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 oVihe San Joaquin Local Health Di§trict. f 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 succi manner as to become subject to workman's compensation laws of California."Contractor's'hiring'oi sub-contracting signature t 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 applica ust a!I for Ire it insi pections. Complete drawing on reverse side. Signed X Title: Date:/ FOR DEPARTMENT USE ONLY Application Accepted by Date 1 -6` Area a Pit or Grout Inspectio ate Final Inspection by LDate Additional Comments: F LIStk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ racy 835-5385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.; P.O. Box 2009, Stk., CA 952p1 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY INFO DATE PERMIT'NO. +.EH 1"3-24(REV.1iH5) EH 14-26