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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 t (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. _ � f a Job Address a City. Lot Sizexoiq Ply t Owner's Name %35 �� Ji�l' � Address Phone Contracto;7?ll� `jLC Address •.-ra License leo.42?�Phone `* 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACIEMENT ❑ 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private I-] GravelPack 171 Tracy Type of Casing Specifications f l Public ❑ Other + ❑ Delta Depth of Grout Seal Type of Grout 'I I irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump t H.P. - i State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth ' Filler Material (Below 501 _ TYPE OFSEPTICWORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it public sewer is H available within 200 feet.) Installation will serve: Residence Commercial 'Other Number of living units: Number of bedrooms 14 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg t CapacityNo. Compartments PKG. TREATMENT PLT. EI ' I I t Method of Disposal .� Distance to nearest: Well i U Foundation Property.Line LEACHING LINE ❑ No: & Length of lines i met Total length/size FILTER BED ❑ Distance to nearest: Well w 60 Foundation F� Property Line SEEPAGE PITS i'l Depth Size,. �ci_��o Number SUMPS D Distanceto nearest: Wel! 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: "1 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: 1 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 applicant must call for all requspections. Complete drawing on reverse side. Signed X .- Title: ----;; P G j� _ Date: -Ski FOR DEPARTMENT USE ONLY Application Accepted by Date _ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781— ❑ Lodi 369-3621 L7 Manteca 823-7104 ❑ Tracy 835-6385 Applicahi- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a FEE AMOUNT DUE AMOUNT REMITTED CR RECEIVED BY INFO CA H DATE PERMIT'NO, r..EH 13-24(REV.t/K51 EH 1I-28 I �(3 ZV �` r3i45 y/a-8rY X? X37