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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON PAVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES1 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 Ryles and Regulations of the San Joaquin Local Health District. Cf ty i p G� L`ot Siie PM Job Address Owner's Name ,� 2e&L47rr1-Addtess Z� � Ge S ki Phone As� �y3 Phone Contractor � � Nv Address � +�g � License No. 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 ❑ Tracy Type of Casing Specifications [I Public ❑ Other El Depth of Grout Seal Type of Grout ❑ Irrigation L--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth l Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septiw hst m permitted if public sewer is availablef Installation will serve: Residence ? Commercial— Other Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: I Water,table depth SEPTIC TANK ❑ Type/Mfg ! Capacity No. Compartments PKG. TREATMENT PLT. C1x Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE N--�*NO. & Length of lines (1 T12 ._ Total length/size FILTER BED ❑ Distance'to nearest: Well Foundation Property Line SEEPAGE PITS 40�'Deptfi Size ` — Number SUMPS Distance to nearest: Well Foundation 113/14 Property Line DISPOSAL PONDS ❑ .i ' I hereby certify that I have prepared this application and that the work will be done V accordance with Sari Joaquin county ordinances, state laws, and �. rules and regulations of the San Joaquin Local Health District. t 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,1 shall employ persons subject to workman's compensa- tion laws of California." x The"applicant must call for all required inspections. Complete drawing on reverse side. Signed l,~p Date' 6 FOR DEPARTMENT USE ONLY i Application Accepted by Date 'J Area I Date Pit or Grout Inspection Date Final Inspection by Additional Comments: 835-6M ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 lE]:Tracyk Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.' Hazelton Ave., P.O. Box 2009, Stk., CA 95209 FEE AMOUNT DUE EAMOUNT.REMITTED CA5H RECEIVED BY DATjEj" INFOCI �n+ EH 13-24 ir:EV.i/s51 - - EH W28