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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT /vim 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Job Address 1 City, T� ot Size PM Owner's Name d �/�, Y tJ�� Address /-� �' Phone Contractor_ s -Z ! -r 16Le"Address t'ca M TeA License No Phorie TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J' PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS o , INTENDED USE TYPE OF WELL PROBLEM AREA(-CONSTRUCTION SPECIFICATIONS ❑ Industrial €❑ Open Bottom ❑ Manteca -% Dia. of Well Excavation Dia. of Well Casing 111 ❑ Domestic/Private ❑ Gravel Pack _❑.,T_racy_ Type of'Casing Specifications } 1"1 Public IF) Other 1 Cl Delta Depth of Grout seal Type of Groui I I Irrigation __Approx. Depth { I Eastern i Su ac Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ iWell Diameter Sealing Material (top 50') - j Depth Filet MatehTBelow' 50 I j TYRE OF SEPTIC WORK:j. NEW INST_ALLATION_Q REPAIR/ADDITION I 1 DESTRUCTION lNo septic system permitted if public sewer is f i _ available within 200 feet.)' Installation will serve: Residence Commerciaf Other t I A Number of living units: " Number of bedrooms t Character of-soiFSd'a depth of 3 feet: t Water table depth SEPTIC TANK- j Type/Mfg - Capacity No. Compartments. PKG. TREATMENT PLT. ❑; Method of Disposal` w. F Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. R Length of lines j Total length/size FILTER BE ❑ Distance to nearest: Well Foundation Property Line I rI SEEPAGE'PITS I I Depth Size t Number t i SUMPS ❑ Distance to nearest: Well Foundation i Property Line t DISPOSAL PONDS ❑, i 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. { I 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 W employ any person,ln such manner as'to become subject to workman's compensation laws of California." Contractor's hiring or suti-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 applicant must call for al required inspections. Complete drawing on reverse side. I �F Signed X Date: I FOR DEPARTMENT USE ONLY Application Accepted by 1 # Date r`g��Q Area it. t� j Pit or Grout Inspection by ! Date f Final Inspection by C- �a�i�i//� - Date/ p Additional Comments: ' i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sax 2009, Stk., CA 95201 FEE AMOUNT_DUE_�.. .WAMOUNT-REMITTED- _RECEIVED By _ _DATE__- ,PERMIT-'NO., ,,- INFO CASH + EH 13.24 1REV.i EH 14-26