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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 herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.— J Job Address Ci Loi Size PM — /7 Owner's Name AddressV% cp i 1-4 N Phone 1 Contractor's Name License No. S 3 Phone YG 6 Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L7, DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE. FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ALJ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _._ Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done -O---Type of Pump — — H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r, Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION TX 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_ —,ai// f 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 I y Distance to nearest: Well Foundation _ Property Line! _ i LEACHING LINE >C No. & Length of lines - '70 Total length size + � FILTER BED ❑ Distance to nearest: Well 4-- Foundation /G' F Property Line S r �- t SEEPAGE PITS D Depth _ Size Number _. e SUMPS :: Distance to nearest: Well Foundation _Property Line' —' DISPOSAL PONDS ❑ • ` I " ' . 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. / -1 t . Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the workfor 1 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 t 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." l The applicant s c I r II req u' d Hsps i s. Complete drawing on reverse side. t t p r Signed X Title: Date: ' FOR DEPARTMENT USE ONLY12 Application Accepted by Date Area + �� Pit or Grout Inspection by Date Final Inspection by 1 r -Dat Additional Comments: / . ' ❑ Stk 466-6761 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 1 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT.NO'. INFO CASH