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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' r (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. Job Address,-, s ` City Lot Ske PM Owner's Name ddress ,J r+) — f Phone �j Contractor Address "�#�� License Nqp Phone 1 . �! 17"� k TYPE OF WELL/P MP: 6JEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION tO I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. t PROP. LINE FOUNDATION. _ AGRICULTURE WELL OTHER WELL ,PITS/SUMPS 'INTENDED USE TYPE OF WELL— -PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Botiorh ` © Manteca Dia. of Well Excavation Dia. 'of Well Casing ❑ Domestic/Private ❑ Gravel Pack-'^`—O Tracfy Type of Casing ___ R r Specifications ❑ Public. ❑ Other ❑ Delta Depth of Grout Seal .-Typeof Grout 3� f ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work`Done t n Well Destruction ❑ Well Diameter Sealing Material (top 50') \]� Depth Filler Material (Below 501 t, i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑i DESTRUCTION ❑ (No septic system permitted if public sewer is �� available within 200 feet.► OQ Installation will serve: Residence_ Commercial— Other j Number of living units:__A� Number of bedrooms �9 f I Character of soil to a depth of 3 feet: Water tattle depth SEPTIC TANK ❑ T e/Mf t I IIII Yp 9 ��( .,_ Capacity �!�r� ;.Nb1'Compartmehts PKG. TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Well Foundation�._v .__ Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well I d 0 Foundation Property Line SEEPAGE PITS ❑ Depth i Size Number MPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." 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- tion laws of California." The applicant must call fnr all required insctions. Complete drawing on reverse side. Signed X Title: [ �� ____7 Date: l FOR DEPARTMENT USE ONLY Application Accepted bycar"' Date r� Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: i c ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- I 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 CASH RECEIVED BY DATE PERMIY'NO. +EH13-24(REV.1/8 5) r EH 14-26 `" �/Z3 j —S4 - J�