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''`-APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Roles and Regulations of the San Joaquin I Local Health District. Job Address 1 City 'r Lot Size P Owner's Name Address � 7 iCGi; Phone Contracto4-172.[.e�1Address �C� �"�DX ��, � • License No.��>�t�� Phon !(? 5' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE WELL _ FOUNDATION AGRICULTURE OTHER WELL PITS/.SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Dia. of Well Casing ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation ---Approx. Depth ❑ EasternType of Grout _y Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') � Depth Filler Material (Below 501 yy TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is r Installation will serve: Residence '/ +�, available within 200 feet.) Commercial_ Other-A __._ Number of living units--1_ Number edroo s_ Character of so'I to a depth of 3 feet: 2/�_�c'��in-r C' ` SEPTIC TANK -- Water table depth Cd'.;Type/Mfg Capacity L?�� No. Compartments PKG. TREATMENT PLT. ❑ Method of DOposa1 Distance to nearest: WellX!�. P-..unclatjon f� Property Line S LEACHING LINE K No. & Length of lines `IO Total length/size 01 FILTER BED ❑ Distance to nearest: Well ` Foundation Property Line 57 SEEPAGE PITS G�' Depth — �� Size Number SUMPS ❑ Distance to nearest: Well r Foundation_ /� r DISPOSAL PONDS ❑ �� — — Property Lino 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 amploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature :ertifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ i ion laws of California." p y persons subject to workman's cnmpensa The applicant ust call for a req ired inspections. Complete drawing on reverse side. iigned i Title: �i Date: 4 FOR DEPARTMENT USE ONLY kpplication Accepted by r✓ } � 11 Date � J Atea 'it r Grout Inspection by Date Final Inspection by Date kdditional Comments: I Stk 466-6781 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK# INFO CASH RECEIVED BY DATE PERMIT`NO, M(REV.