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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 70LCityal�ll Lot Size PM Owner's Name - Address Iq77 Phone.` ContractL6Address O . License No.. Z?� Phow-5 In TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CI i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WAL OTHER WELt PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`I Public Cl Other 1=1 Delta Depth-of Groui Seal Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.- State Work Done Weil Destruction ❑ Well Diameter Sealing Material (tap 50'1! / Depth Ilex Material (Belovr.50') TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAI /ADDITION W DESTRUCTION I i Mo septic system permitted if public sewer is } available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: —I— Number of b o,ms \ f ` Character of soil to a depth of 3 feet: >, Water table de T pth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _� Method of Disposal Distance to nearest: Well Foundation PropertV,Une LEACHING LINE PI'N.. & Length of lines b Total length/size''-'- X FILTER BED ❑ Distance to nearest: Well.. , Foundation /d Property Line +. SEEPAGE PITS le -Depth Size -' _ Number Z { r SUMPS Ll Distance to nearest: Well /06 Foundation 4_0 Property Line DISPOSAL PONDS U 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. 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 taws of California." Contractors 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 mu call far all qui ed inspections. Complete drawing on reverse de. + Q Signed X Title: �. Date: FOR DEPARTMENT USE ONLY /D- 7 Application Accepted by // Date p Area J �or Grout Inspection by Dater47Final Inspection by Date' Additional Comments: ❑ Stk 466-6781 0 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 -` INFO AMOUNT DUE AMOUNT REMITTED CASH+�_Y RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.I/H 57 /� (� 3 EH 14-26 i Y