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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED D �� (Complete in Triplicate) Application is hetehy 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 bistrict. Job Address 7 S r 57- City stBeG T--_'Lot Size PM Owner's Name 7/ e—a P/eZC,--1---4-Address �� Phone Contractor � +` Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO `� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLE A CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/,Private ❑ Gravel Pack El Tracy Type of Casing Specifications M Public ❑ Ot {1 Delta Depth of Grout Seal Type of Grout h I I Irrigation "I P' Depth { I Eastern Surface Seal Installed by Repair Work Do Type of Pump H.P. State Work Done Well D ction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEP WORK: NEW INSTALLATION I:1 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation!;will serve: Residence_ Commercial_ Other Number of'iliving units: Number of bedrooms 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 Distance to nearest: Well Foundation Property Line C LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED!. ❑ Distance-to nearest: " Well Foundation -Properly Line it SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 1. 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 employ p y an y person in such manner as to become subject to workman's compensation taws of California."Contractors 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 an must call for all requii nspectiq s. omplete drawing on reverse side. Signed X !! Title: Dale: 10 OR EPART NT USE ONLY Application Accepted by - Date 6 Area Pit or Grout Inspection by Date Final,Inspection by to Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63.85 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 li FEE i NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. r EH 13-24 iItEV,t/N51 7: