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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 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 p Job Address _l .7 SSR',. GC�(tT� D 6 �_ 3 �iy�iy City OLot Size PM Owner's Name Address �z�6 e , ( ( j' 2 _3ij Phone 3 / / a Contractor C' r r [o• Address }• Z— , �� License No.��_226 Phone ��-5 /C+_i \ TYPE OF WELL/PUMP: NEW WELL p— WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE L!� 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 Weil Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout t� V ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by \\ Repair Work Done El Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material flop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is available within 200 feet.] Installation will serve: Residence I'll, Commercial_ Other a Number of living units: ✓ Number of ooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK l'Type/Mfg Capacity ld._ No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Weil�� Foundation _._. Property Line LEACHING LINE 8--No. & Length of lines Q Total length/size Q FILTER BED ❑ Distance to nearest: Well �d/ Foundation f b_ Property Line�_,-_ SEEPAGE PITS Deph tSize ! Number SUMPS ❑ Distance to nearest: Foundation- Property Line S DISPOSAL PONDS Cl 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. f 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 shallfnot employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting sigma ture 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 corripensa- tion laws of California." The applica ust tali for ql4oq 'ed inspections. Complete drawing on reverse sid . Signed X - Title: t Date: ti FOR DEPARTMENT USE ONLY ! Application Accepted b±by _ Date ! Area Pit or Grout inspection Date c Final Inspection by ��- :Data -_c � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca -7104 ❑ Tracy 835-6385 Applicant - Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNTREMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH ♦ EH 13-24(REV. (� . EH 14-26 C/ (JX