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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466-6781 I I PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED 1N10 (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. Job Address Z_'40 in A *A) City Lot Size PM Owner's Name ,� V �yif111C Address I Phone Contractor -Q— Address License No.�Phone TYPE OF WELL/PUMP: . , NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTJON SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ElIrrigation _,Approx. Depth ❑ Eastern - _ Surface Seal Installed-by Repair Work Done ❑ Type of Pump H.P. State Wor".Done; Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR"/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence'— Commercial— Other--w Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity y No. Compartments PKG. TREATMENT PLT. ❑ I — Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number ) SUMPS ❑ Distance to nearest: . Well Foundation Property Line DISPOSAL PONDS ❑ a I 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. 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 any person ih such manner as to become subject to workman's oompensation laws of California."Contractor's 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.” G The applicant must call f all required inspections. Complete drawing on reverse side'— Signed X 1 � �-- Tiile:°-�-� s_ �'� - Dater OR DEPARTMENT USE ONLY 1 Application Accepted by Vn� _ r` ,ep0�1 Date Area i �yy I Date Final Inspection by Date D8 Pit or Grout Inspection by �y Pe Additional Comments: ❑ Stk 466-6761 ❑ Lodi 69 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 !1 Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 —FEE — .v MOUNT SUE AMOUNT REMITTED`T CK ti Y' RECEIVED by `R —IDATE w PERIViIT N0 INFO (CASH, + EH13-24(REV.1/851 3S,Dc� 3�[JU ^ 6 33 4� EN 114-20