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a APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT V1� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)-46781— �l 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 City ^ Lot Size SOX10 PM Owner's Name Address ? �` Phone i�✓ Contractor �� Address License No. Phone_ ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARE TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A NST ❑ Industrial ❑ Open,Bottom- ----- ---- Dia: of a tion Dia. of Well Casing ❑ Domestic/Private ack _❑ Tracy Type of Casing. — Specifications 1-1 Public Cl Other F1 Delta _`._�.. Depth of Grout Seal pe of Grout _ I I Irrigation _.-Approx. Depth I I Eastern "'Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 1 State Work Done Well Destruction ❑ Well Diameter Sealing Material/(top:50') Depth- 'Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INST ELATION I I REPAIR/ADDITION L) DESTRUCTf ) (No septic system permitted if public sewer is available within 200 feet.) ,M Installation will serve: Residence Commercial— 'Other ( �1 Number of living units: Number of bedrooms 1 01 Character of soil to a depth of 3 feet: r" ` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ iI 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: "1 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 must call for all required Alspection000tomplete drawing on reverse side. i Signed X Title: �/.1.1/1 / Date: 4 I FOR DEPARTMENT USE ONLY (� J � I Application Accepted by Date Area I 1 Pit or Grout Inspectio �1 bate Final Inspection by Date Additional Comments: /Uy / � �`r�U�" I ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO is {i +.EH 13-24(REV.1/8 5) d rT:;t— /I J EH 14-26