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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICOmplete in Triplicate) i 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 i Local Health District. I1 Job Address City � �"�' Lot Size PM i i Owner's Name �r�/� Address �� ! ' "lY`-i' Phon3Z3� Contractor e, Address C� �� 17- `---max •1-J—ZL License No.& 23 7-3 Phone Z�1 TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION FT � SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE qF WELL `PROBLEM AREA COMTROCTION-SPECIFICATIONS'`— '— ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ' Type of Casing Specifications ❑ Public Ll Other Cl Delta ti Depth of Grout Seal Type of Grout _ I 1 Irrigation -Approx. Depth I I Eastern t Surface Seal Installed by - Repair Work Done a Type of Pump H.�. ifF State Work Done _ \, Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR(ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ 011her Number of living units: ' Number of bedrooms Character of soil to a depth of 3 feet: i l Water table depth r SEPTIC TANK ❑ Type/Mfg �kkk Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well ! F'�oundatidn;, --I Property Line LEACHING LINE ❑ No. & Length of lines Total length/size— FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 1 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ k application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I i hereby certify that I have prepared',this app q tY l rules and regulations of the San Joaquin Local Health Di1trict. 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 parsons subject to workman's compensa- tion laws of California." The applicant u cal or all requir inspections. Complete d,awing on reverse side. ` Signed X title: _ /z`-'� Date: ..1 _� i FOR`DEPARTMENT USE ONLY Application Accepted by ��r C1 ! -_ Dat Area f �� Pit or Grout Inspection by Date ? Final Inspection,hy,t JVh Date rz/! � Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r INFO ('�' +.EH13-24(REV.r/K5) (17 - �-� v ( ZoZtP EH 14-29 GGG.••JJJ (