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APPLICATION FOR 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. ,, Job Address(Q 4X3 , ' ,� '^`" City Lot Size 0&9PM Owner's Nam PA Address d Phone Contract 4tAddress .® r ' 07 UC LA' License No. a a� Phone Sl�� 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack _. _...-O,Tracy___.. Type.of Casing _ Specifications €'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth er Material (Below 50') QV TYPE OF SEPTIC WORK: NEW INSTAL4ATION l 1 REPAIR ADDITION DESTRUCTION I I (No septic system permitted if public sewer is r// - available within 200 feet.] Installation will serve: Residence� Commercial Other Number of living units: I Number of drooms ! r Character of soil to a depth of 3 feet: — Water table depth 70 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line � f LEACHING LINE 3KNo. & Length of lines ....._f__ Q "Total length/size U ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 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 wank will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: '11certify that in the performance of the work for 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 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 applicant t call for all qui d inspections. Complete drawing on rev�ersfe sI Signed X Title:~_ V t p,� Date: 7 FOR DEPARTMENT USE ONLY // Application Accepted by j Date ,G � � Area Pit or Grout Inspection by Date Final Inspection by Date// 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 CASH RECEIVED BY ///DATE PERMIT'NO. + EH 13.24 I REV.S/H 57 EH 14-28