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APPLICATION FOR PERMIT S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,.STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED(Comp fete 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 city Lot Size PM Owner's Name Address `s22 VO Phone Address # ,m s � ;License No. Phone I Contractor A - •� k r.- . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ----,-.o.SYSTEM REPAIR-❑x= -- _-- -OTHER ❑-- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ _ DISPOSAL FLD. PROP. LINE , l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca..., —Dia-of•Well•Excavation Dia. of Well Casing [_1 Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑1. Delta Depth of Grout Seal Type of Grout rx. Depth . ❑ Eastern Surface Seal Installed by El Irrigation �ApP � � i Repair Work Done ElType of Pump ;H-P• State Work Done I Well Destruction, ❑ Well Diameter Sealing Material (top 50') Depth ;Filler Material I8elow 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION (No septic system,permitteqsewe, e� + available within 200,feet.)0 Installation will serve: Residence t Commercial_ Other Number of living units: �{ Number of bedrooms Character of soil to a depthrofi3 feet: Water,table depthi SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _t PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE El No & Length of lines } --Total-length/size----* a k .. FILTER BED ElDistance to nearest: Well Foundation Property Line Size h Number �. SEEPAGE PITS ❑ Depth t �� , V SUMPS ❑ Distance to neatest: } ` �" Foundation " .f°`�Propgrty Line DISPOSAL PONDS ❑ C _ '/:s i �* ...o �' , -' r.w r ;7 .,I �a: �. F 1 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 m t tail for all requiredins ctions. Complete drawing on reverse side. Signed Title: ate: OR QEPARTMENT USE ONLY c2 J . Application Accepted by Date Area ` v Pit,or Grout Inspection by Date Final inspection by Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 . ❑ Tfacy 835- Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk:, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. k INFO 3� � � '�S�a a ' + EH 13-241REV.i/:�+-si 00 EH 1426