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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address c City Lot Sizec2 PM Owner's NameAddress < l[/+ Phone O �� Contractor / 9�"';4�Y ddfess ' C>. C License No. �Y`� Phone TYPE OF WELL/PUMP: NEW WE/L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATN ❑ SYSTEM REPAIR ❑ , OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL'FLD PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL Y - —PITS/SUMPS INTENDED USE TYPE OF_ LL PROBLEM AREA CONSTRUCTION:SPECIFICATIONS A j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation Y Dia. of Weil Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casing-- Specifications ❑ Public ❑ Other ❑ Delta Depthrof Grout Seal_. _ Type of Grout ❑.Irrigation; r a 4-Se "tall = _ —Approx. Depth ❑ Eastern Surface Sea! Installed by Repair Work Donb ❑ Type of Pump �. H.P. State Work Done_ Well DeWuction .0 - ` Well Dameter " Sealing Material-(top 501 Depth rtFiller Material-(Be-low 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/A[IDITION- --DESTRUCTION ❑ (No septic system permitted if public sewer is, available within 200 feet.) Installation will serve: Residence .-Commercial_ Other- ' Number of living units: _L_ Number of droo s Character of soil to a depth of 3 feet: t Water table depth 02v SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE 10No. & Length of lines J~ r Total length/size Vim^ FILTER BED ❑ Distance to nearest: Well� Foundations Property Line _ A SEEPAGE PITS Depth Size J1lurnber SUMPS ❑ Distance to nearest: Well: I&Q1 Foundation'. L Property Line__s5 DISPOSAL PONDS ❑ `�` -� 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 peinit 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 certifies the following:"I certify that in the performance of thel work-for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The appli]MiE fortions. Complete drawing on reverse�,jde. Signed XTitle: Date: 7 1 FO DEPARTMENT USE ONLY ApplicatioDate Areaor GroDate ^ Ina Inspection by �"-�'"mate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 40 CASH RECEIVED BY PATE PERMIT'NO. + EH13-24(REV.1/n 51 40 EH 10.28 i r