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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.; STOCKTON, CA Telephone (209) .466-6781 , PERMIT EXPIRES TYEAR 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 D 0, iv 0,V City Lot Size PM Owner's Name Z)o, mind X71 r'A/ Address � i Phone I Contractor�-5' 'Q r Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATiO ❑ SYSTEM R AIR E71OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHE=R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE REA COfVSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy -`f'Type of Casing Specifications F1 M Public Other D Delta Depth of'Grout Seal Type of Grout I ! Irrigation _.-Approx. Depth I I Easte/rn i i Surface Seal Installed by Repair Work Done" ❑ Type of Pump,. / IH.P. '� State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I .DESTRUCTION lNo septic system permitted it public sewer is . available within 200 feet.) Installation will serve:' Residence— Commercial_ Other i1 Number of living units: Number of bedrooms { s> Character of soil to a depth of 3 feet: Water table depth /1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: -Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �- FILTER BED ❑ Distance to nearest: Well Foundation Property Line , SEEPAGE PITS {"I 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 i rules and regulations of the San Joaquin Local Health District. i 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 must call for/all required insp�ectiioons. Complete drawing on reverse side. Signed XTitle: (,2 ` A1 Date: z FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Tlspecttqn by Date Additional Comments: c / I 1. ``-'_VP l { ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O 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 {)ATE PERMIT NO. INFO CASH + EH i3-24{REV.I i N 5) '. "' �� ! ' V� 6 Y E•H.114.26 F.