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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, h (' �j� fAi Job Address City SZ Lot Size` 4&t-07 * PM Owner's Name Address Phone Contractor dress_- A I,/ License No i o Phonyv? 1,2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t I PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O S J 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation L_-_- pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type'of-Pump H.P. State Work Done Well Destruction '❑ Well Diameter Sealing Material Itop 501 -. Depth . Filler Material (Belo ') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is "'available within 200 feet.) Installation will serve: ResidenceCommercial_ Other + Number of living units:t Numberr of bedrooms j Character of soil to a depth.of-3 feet: Water table depth ' SEPTIC TANK ❑ T e/Mf yp g I AU ol pacify No. Compartments PKG. TREATMENT PLT. ❑ Ij Method of Disposal Distance to ns_/1XWe"11 eareFoundation Property Line i LEACHING LINE No. & Length of lines Total length/size ya. FILTER BED ❑ Distance to nearest: Well sit Foundation 51D Property Line SEEPAGE PITS ❑ Depth -2 ize Number 36 SUMPS { El Distance to nearest: Well/4�C�7' Foundation 6 d ' Property Line DISPOSAL PONDS ❑ _S 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 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." °. t The applica must call r ail required inspections. Complete drawing on reverse side_ Signed X ? Title: rfl/( Date: R T USE ONLY Application Accepted by Date Area Pit or Grout Inspection by bate Final Inspection by_ �:dg, V1�� 3Z3�N`� Date ~S-7 Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Ak Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 it FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i + EH 13-24(REV.t/H5) EH 1428