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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. Jab Address I V City J Lot Size 9._-.✓.�Y X0 PM .. Owner's Name Address PhoneY6..2— Contractor 4dress Z 73fu L _ _License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ED DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN S DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULT E ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAE SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Did. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public F1Other r7Delta Depth of Grout Seal Type of Grout --- I I Irrigation Approx. Depth I 1 Easte Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done, Well Destruction ❑ Well Diameter Sealina Material {top 50'1 Depth_ iller Ma erial Relp-50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/AD ITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commerci I -- Other Number of living units: Number of bedro # Character of soil to a depth of 3 feet: Y Water table depth SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: W II Foundation Property-Line ;ti I ; LEACHING LINE LI No. & Length of lines T l length/size r FILTER BED L1 Distance to nearest: Wel! foundation Property Lin SEEPAGE PITS I ] Depth r _ Sixa Numbef" i SUM SS ❑ Distance to nearest: Well .Foundation Property Line , DISPOSAL PONDS ❑ ' 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 DFstrict. i 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-7;�, tion laws of California." The app71,fl-bo7n must call for quired ins tions. Complete drawing on reverse side. i Signed Title: t�i�� . Date: lorFOR DEPARTMENT USE ONLY Application Accepted by Dat E\tree 5 } Pit or Grout Inspection by Date Final Inspection by Data E Additional Comments: i ❑ Stk 466-6781 ❑) Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., 6A 95201 FEE INFO JMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY D TE PERMIT'NO. +.EH t3-24{REV.i i H sl .� �� G _ EH 1428 L3