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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ® ��a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) OC2v Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descrif]2d Thlgffiplication 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. E-NVIRC NiVlul'viA? IJEALTH PERM11'/SERV;CES Job Address �u �T^r City Lot Size PM Owner's Name �,t / �t/d� tfJ�� Addressy Jp al, rx- A � - Phone � ContractorLl Address 41. c, License No.2—GS7G ` Phone �'" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION N' SYSTEM REPAIR 44-- OTHER ❑ DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 5�-Bomestic/Private ❑ Gravel Pack ElTracy Type of Casin1g Specifications 171 Public M Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I 1 Easterny Surface Seal installed by Repair Work Done L3 Type of Pump � /H.P. X2_ Avelf State Work Done Well Destruction ❑ Well Diameter — le ore Sealing Material Itop 501 Depth Filler Material (Below 50`) TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 1✓� Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ..❑ Type/Mfg Capacity No. Compartments 'r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation l 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 L� Distance to nearest: . Well Foundation Property Line r 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 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: "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 cal all required ins pe ions. Complete drawing on reverse side) Signe l" Title: ► �S�///�i>�a 2 Date:A;� 7 e s FOR DEPARTMENT USE ONLY " s Application Accepted by Date r Area Pit or Grout Inspection by Date Final Inspection by Date 149' - 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH .. EH 13-24 IREV.1/"9) EH 14-213