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s 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. Cit Ls � 5 Job Address w' �� - Y Lot Size PM Owner's Name CO- _�f' a Addres Phone r- �� ®. G>9x C• _ Contractor W' '�P£ �rl��1+� Address �i�IGo�'e C�S� License No.3763`/5 Phone 35 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�I "t OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIW16 L7 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation_ Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing pecifications ('] Public (1 Other F-I elta Depth of Grout Seal I I r ype of Grout I I litigation Approx. Depth 1'f Eastern Surface Seal Installed by Repair Work Done UType of Pump H.P. State Work Done Well Destruc ion 1-_/Well D7' 'n it Sealing Material (top 50'1 ?Q 7,vo' DepthFiller Material (Below 501 e� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth __ Size Number SUMPS t.1 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 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."Contractors 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 applic t c �rr all required inspections. Complete drawing on averse side. LIC (�Signed X2'L�� Title: 1%Ll��o 9c. Data: FOR DEPARTMENT 1.14 ONLY Application Accepted by Date Area Pit or Grout Inspection by Date � Final Inspection b Date Z 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 CK H RECEIVED BY TDATE ^} PERMIT'N/O./ . EH13-24(REV.i/n 5) EH 14-26 TTT��