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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELLTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 Ryles and Regulations of the San Joaquin Local Health District. p g Job Address l�i Z �� - - City Lot Size / /7 C- PM Owner's Name Address lo`4' e&0,4e '` C1 (elf" Phone Contractor Address _ s /yl�3 License No. —�� Phone 'lK� TYPE OF WELL/PUMP: 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewlis available within 200 feet.] Installation will serve: Residence Commercial_ Other Number of living units: Number of edrooms Character of soil to a depth of 3 feet: If e a Water table depth SEPTIC TANK ❑ Type/Mfg CapaciNo. Compartments 74/ c PKG. TREATMENT PLT. ❑ l / Method of D1 ,o.�sal Distance to nearest: Well/SD Foundation D Property Line LEACHING LINE ❑ No. & Length of lines 4J Total length/size Q FILTER BED ❑ Distance to nearest: Well Foundation od Property Line d Y SEEPAGE PITS Crl DepthSize N umber yy`� -7L SUMPS El Distance to nearest: Well�0 Foundation-FV- Property Line��5]2 l DISPOSAL PONDS ❑ / 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. 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, l 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 fallowing:"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 Callforni .' The applican u call for all re a inspections. Complete drawing on reverse side. r/ Signed Title: /��'\a/ly Date: FOR DEPARTMENT USE ONLY ;Mro eipection ed by Date 7 !" 4a Area - by ate -ell , r� inal Inspection by Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all chpll�s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. ox 2009, Stk., CA 35201 Ijp /_ % �� /��C/`-J FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT''NO. INFO + EH3-24(REV.i/e5) EH 1428 1 �` �S S