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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 (Complete in Triplicate) I 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. � Job Address "t"Z_t City C- Lot Size PM Owner's Name �1 i �� 4),7 34cr1� Address Phone � ,�,-_ mac_ '�`� Contractoif�`��'°-� Address ` �� l � - �a��Lcense No. �✓p6 Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION I `"'.-SYSTEM REPAIR C OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 )�(_DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Cl Other D Delta Depth of= Grout Seal Type of Grout t I I Irrigation Approx. Depth I 1 Eastern _ urface Seal Installed by Repair Work Done �. Type of Pump H`P. � A` State Work Done Well Destruction C1 Well Diameter *} Seaiin aterial Itop 50'1 Depth f t Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION l I (No septic system permitted if public sewer is `}1 available within 200 feet.) tN 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 PropertV.Une LEACHING LINE ElNo. & Length'of lines Total length/size i + arm. _- FILTER BED ❑ Distance to nearest: Well `.Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Welt Foundation Property Line DISPOSAL PONDS ❑ f 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 Diltrict. 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 trot 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 applica call for all required inspections. Complete drawing on everse side., . Signed O( , _ �� Title: � - Date: ,j OR ARTMETtT USE ONLY r� YApplication Accepted by Date Area-fel= Pit or Grout Inspection by Date Final inspection by Date.3-31-ff5 ._ Additional Comments: I E3 Stk 466-6781 ❑ Lodi 369-3621. 0.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 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO / t +.EH 1324(REV.1/H 51 �! EH 14-26 }