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APPLICATION FO J 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. n per, Job Address -P �' /] _ ,.,_. City T.• '-� Lot Size � �—�— PM Owner's Name E/l Address _ A Phone CJ �d COn{ractor d Line No.� fDW,f Phone `5 TY ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SE K SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V I"1 Public CI Other [7 Delta Depth of Grout Seal of Grout I i Irrigation --Approx. Depth { I Eastern 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 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION l I DESTRUCTION I I (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 oz Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 9�_Type/Mfg Capacity_- � No. Compartments PKG. TREATMENT PLT. ❑ f Method of DispgSal Distance to nearest: Well Foundation 2,Od Property Line f� �/ (� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 permit is issued, I shall noLl� 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: "1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The appfica ust all f all req 'red in tions. Complete drawing on reverse side. Signed Title: Date: R DEPARTMENT USE ONLY ,Q Application Accepted by Date v �� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: slyA ze ❑ Stk 466-6781 ❑ Lodi 369-36ZI ❑ 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 CASH RECEIVED BY DATE PERMIT'ND. + EH 13-24[REV.tiHSY EH 11-28