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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 City TQX/L ot Size Xig"Z/ ��e PIVI Owner's Name C/ g��i� W'y i5�IPSO.Aiddress L„ / c� / ��e Phone 601ff Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ OEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �- AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLE ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of ation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy �' Type of Casing ' x Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal of Grout ❑ Irrigation JApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth „_Filler Material (Below-50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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: Water table depth SEPTIC TANK ❑ Type/Mfg + 6 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal. Distance to nearest: Well Foundation Property Line " t LEACHING LINE ❑' No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth ' Size Number 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. ' 1. 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust tail for all requi a spa ns. Complete drawing on reverse side. Signed Title: _ Date: FORD TMIENT USE ONLY Application Accepted byDate Area 0 =;I— Pit Pit or Grout Inspection by Date Final Insp ction by Date / `��" Additional Comments: Q ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.95X1 FEE INFO AMOUNT DUE AMOUNT REMITTED C 3 RECEIVED BY DATE PERMIT-NO. + EH 13-24(REV.i/x 5) 1i"1 EH 14-M J� (-1 ` D I (j,J