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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E. HAZELTON AVE., STOCKTON, CA ; Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in,Triplicate) -:y to 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. ►?y . �y r Job Address r Zr� s�� S% city Lot Size PM Owner's Name f' G��d Address __l�O_ E I � ''�� - Phone Contractor '" �� Address � � ` � � License No. �� '� Phone -26/- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL . PROBLEM AREA r�CONSTRUCTION SPECIFICATIONS ❑ Industrial 11Open Bottom Q Manteca Dia. of Well Excavation ''" Dia. of Well Casing ❑ Domestic/Private ❑ 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 ❑ Type of Pump H.P.`-'`--- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below'501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO No septic system permitted if public sewer is available within 200 fee .1 Installation will serve: Residence Commercial_ Other ti �1L Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ',r'Water' ble depth SEPTIC TANK ❑ Type/Mfg CapaciNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines% Total'l6hgth'/sire FILTER/BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ]—Size Number ; SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAUPONDS ❑ _ _ 1 - ,l 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."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 shallemploy persons subject to workman's compensa- tion laws of California." ♦w` j F The applicant must a r all requ' dins s. Complete drawing on reverse side. , f�-zF-7 Signed Title: Date: FOR DEPARTMENT USE ONLY j r Application Accepted by Date [ r Area Pit or Grout Inspection by Date ^:Final Inspection by. Date's• Additional Comments: - G ! 0 Stk 466-6781 0 Lodi 369-3610 ❑ Man eca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental/Health Permit/Services 1j6�0.1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH CK RECEIVED SY DATE PERMIT`NO. +EH 13.244REv.t/a¢1 �/ ! M EH 14-28 '. 7