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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 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei ibed pplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reg Joaquin Local Health District. t" 5e\ � - SeaV i Job Address S L2X0 City. Lot Size Owner's Name �c ' Address • /11001 St• ��tk7�'�Qa —A Phone Contractor /� 171� Address I�� A,'hol� , Wta��-�eZ License No. Phone[ /S � ' 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 ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing Z ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ley '_ Specifications r tn�� i ❑ Public �1 1z, Other llDelta Depth of Grout Seal �o� Type of Grout CoYtL ❑ Irrigation r i( f1r W"I------Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 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 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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." 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 applica ust call for all required ins coons. o plete drawing onn reeveersee/side Signe- Title: �Z Date: FITMENT USE ONLY pl Application Accepted bDate �.�� O J Area Pit or Grout Inspec' y D to Final Inspection by Date Additional Comments• ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823X10, ❑ fracy 835-6385 Applicant - Return all copies to: Environ ental ea Pe-it/�S(e�vices 1601 E. Hazelton ve., P.O. x2009, tk. CA 9520 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 13-24{REV. 8 // EH 74-26 t 5! "t3 '1 V Lfl g ZIR78p � O