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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 ` Lot'Size PM Owner's Name e: Address ��-� phone II Contract��l rl C Address ' k®, �C �f� A d? r 7Z p 2 Z� 6�5 —,S' 0S License Nom _- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL... .OTHER WELL- PITS/SUMPS.- .-INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom t ,❑ Manteca.1 Dia. of-Well Excavation Dia. of Well Casing _❑ Domestic/Private ❑ Gravel.-Pack. . - .__.❑,Tracy. Type of Casing . - -- —.5peci#ications ❑ Public ❑ Other . ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well-Diameter'"" — Sealing Material (top 501 Depth Filler Material (Below 501 iN TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is N available within 200 feet.) Installation will serve: Residence Commercial ther Number of living units: Number of edrooms 1 � r Character of soil to a depth of 3 feet: , Water table depth SEPTIC TANK ❑ Type/Mfg ; Capacity No. Compartments r PKG. TREATMENT PLT.Q -_ �. _ J Method of Disposal Distance.to nearest: Well, Foundation Property Line 1 .'. _ LEACHING LINE C�No. &,Length ofline's — Q Total,length/size x FILTER BED ❑ Distance-t nearest: Well slV Foundation—140 Property Line SEEPAGE PITS ❑ r Depth. Size Number SUMPS ❑,f,Distance to nearest: Well Foundation - Property Line j D15PO�At POND-S'""4C] I _, k 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 q� 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 1 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:.'(certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tianClaws of California." -+ f The applicant must call fVrpeq-uiiredd inspections. Complete drawing on reverse sides q/ Signed Title: ' � a -FO`R DEP, T TENT US ONLY Application Accepted by Date �~ Area Pit or Grout Inspection by Date Final Inspection by Date ' Additional Comments: ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(F1Ev.1 5) —7 EH 14-28 ( �Ip