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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 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 /7 rCity Lot Size PM �'� Owner's Name j �4`L1,� Address Phone Contractor i k )A C-+k)A __ Address ' If License No. q2nC/Z19 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 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 ❑ Tracy -Type of Casing Specifications (`l Public ❑ Other f7 Delta.. Depth of Grout Seal Type of Grout--.—. i I Irrigation _..Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 �_ TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION I ) DESTRUCTION l I (No septic system permitted if public sewer is � �� available within 200 feet.) Installation will serve: R *dente ��Commercial Other Number of living units: � Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK it ype/Mfg Capacit}/� ]_ No. Compartments PKG, TREATMENT PLT. ❑ r Method of Dispo al Distance to nearest: Well,.,,_ Foundation 0_ Property Line LEACHING LINE Li.rAler& Length of lines ` Tot9ength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Sizer N Per SUMPS %;i.--Istance to nearest: Well Fndatio Property Line o t DISPOSAL PONDS ❑ 1V 1 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 11 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature�S 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 cdmpensa- s of California The applic t c for�r. red �p@c. ons. omp te,drawing on r Sig Date: FOR DEPARTMENT USE ONLY /. Application Accepted by Date '"" —<?17 Area Pit or Grout Inspection by T Date+ �— Final Inspection by 1) t. /'o 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 CK RECEIVED BY DATE LPERMIT'NO. +.EH 13-24(REV.1/H 51 —76 vo EH 1426