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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 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. f � n n Job Address 1 e" __� Q" t �0� 910 City._��ot Size PM i L !^i I4r`/-. Phone Owner's Name � 1 �"V!41<_�t/� Address Contractor _ ��i Address License No Phone TYPE OF WELL/PUMP: e 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".mow TYPE OF WELL PROBLEM AREA ,CONSTRUCTION SPECIFICATIONS r ❑ Industrial Q Open Bottom ❑ Manteca Dia."of Well Excavation ` Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public v .t F1 Other �❑ Delta Depth of Grout Seal Type of Grout _ 1 I Irrigation t i Approx. Depth- I 1 Eastern Surface Seal Installed by Repair Work Done 07- Type of,Pump^""" H'.P:"'""""'��- State Work Done_ Well Destruction t ❑ Well Diameter Sealing Material [top 50') w Depth Filler Material (Below 50') __ N TYPE OF SEPTIC WORK: NEW INSTAL I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) J Installation will serve: Residence_ Commercial_ Other t Number of living units: __L_ Number of bedrooms _ 3 ' i1 Character of soil tg a depth of 3 feet: Water table depth SEPTIC TANK ❑ 3•Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,.❑ Method of Disposal. i Distance to nearest: Well Foundation Property Line ; LEACHING 'LINE No. & Length of lines gd r "Total length/size G ' FILTER BED ❑ Distance to nearest: Well I !k 6x Foundation _•-,Property Line SEEPAGE PITS l I DepthSize = I/Numbef SUMPS ❑ Distance'to neare`sc: ""Weli Foundation Property Line DISPOSAL PONDS ❑ f { I hereby certify that I have prepared this application and that the work will bedonein accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D[�trict. Home owner or licensed agent's signature certifies the following: "I certify that in th,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,i$suacl, I shall employ persons subject to workma 's compensa- tion laws of California." /�;, The applicant must call for all req fired inspections. Complete drawing on reverse side. _ - ' Signed Title: Date: FOR DEPA MENT USE ONLY Application Accepted by Date / Area Pit or Grout Inspection by Date Final Inspection b Date 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 CASH CK " RECENED By DATE PERMIT'NO. a EH 13-24[REV.I A 51 �Y14 N O EH 14-26