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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heiaby 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. .G l /�<. Lot Size """~� Job Address �� Ci/�--� � � ty PM,�� f Owner's Name bo-j,, Address Phone Contractor 4, 40 Address es l'' % License 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 i 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout . I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work bane ❑ Type of Pump H,P. Stats Work Done_ Well Destruction 0 Well Diameter Sealing Material (top 501 !� Depth Filler Material (Below 501 \1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION t I INo septic system permitted if public sewer Is ` available within 200 feet.) lInstallation will serve: Residence Commercial_ Other r Number of living units: 4-_ Number of bedroomb._,.. Character of soil to a depth of 3 feet: �' Di— s1.t,�lw'l Water table depth j SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑, No. & Length of lines _P72 Total length/size f FILTER BED Distance to:nearest: Well Foundation '3 Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Welt Foundation Property Line 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: "t 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 must call for all re aired inspections. Complete drawing on reverse side. r7 ,.,Signed X_—��(� _ Title: � - Date: FOR DEPARTMENT USE ONLY +� Applic�' Accepted bby Date �r Areas it �}``r rXin: by bate Fina{ Inspection by Additional Comments: } Cl Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFNEE AMOUNT DUE AMOUNT HEMITTED C CK ll RECEIVED BY DATE PERMIT'NO. + EH 13-24 rREV,t x sly EH 14-2a / LLL�� L- ••