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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (Complete ih 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 r-ade 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 I Local Health District. Job Address tom`y�f _ City Lot Size PM Owner's Name�l��s 8�,,t&&'Ktr��C y `AdaessP / �s rl_ ACT0 4" 1J -i Phonei z Contractor Address License No. Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ } r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F 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 f7 Public ❑Other t-I Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth t 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 x TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 PEPAIR/ADDITION I I 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 t PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line �j LEACHING LINE ❑ No. & Length of lines Total feingth/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line is SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well 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: "I certify that in the performance of the work for which this permit is issued, l 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." + Thea applicant st r requi ins pp q pecti ns. ompiete drawing on reverse side. Signed Title: — Date: FOR DEPARTMENT USE ONLY Application Accepted by Date RS Area Pit or Grout Inspection by Date Final Insppe/�/f, tion by ` Date d" Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE INFO AMOUNT DUE AMOUNT REMITTED SH F1 RECEIVED BY ,DATE PERMIT'NO. �r r.EH13211REV.1/>+51 p� EH 1429 ZZ20 d f(D