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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephoht (209) 466-6781 PERMIT EXPIRES 1 YEAR FROW 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. Job Address'—b do d'©^ �� - ,City Lot Size PM r r ; Owner's Name ' < Address5-Y b 6O l` Phone Contractor ``-' Address O License No.! e �1--3?3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ � SYSTEM REPAIR [fi OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE`WELL OTHER WELL PITS/SUMPS r: -INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p ❑ Industrial ❑ Open Bottom ❑ Manteca Dia:of Well Excavation I Dia. of Well Casing f Gi,IIomestic/Private ❑ Gravel Pack` ❑ Tracyl Type of Casing Specifications -D Public F] Other ❑ Delta Depth of Grout Seal Type of Grout I ❑ Irrigation --Approx. De ❑ Eastern Surface Seal Installed by Repair Work Done V Type of Pump V �`�C -ZH.P. State Work Done 1 + Well Destruction ❑ Well Diameter i' Sealing Material (top 501 , Depth Fller Material (Below 501 TYPE OF SEPTIC WORKi NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ I(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other { t. Number of living units.: Number of bedrooms 1 moi-•Character of soil to a depth-of 3 feet: 3 z A.r. .,'-. .; ��' ' Water table depth . _ _,SEPTIC TANK`� ., ❑ Type/iMfg Capacity ; No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ElNon&`Length 6f lines Total length/size FILTER BED ❑ Distance,to nearesta, Well FoundationProperty Line Z F SEEPAGE PITS ❑ Depth y Size Number SUMPS ❑ Distance to nearest: Well Foundation jProperty Line 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 sig nature certifies the following: "I certify that in the performance of�thb work for which this permit is issued, I shall not employ any person in such mannee as'to become subject to workman's compensation laws of California.",Contractor's hiring or sub-contracting signature certifies the following:"I certify that inrthe 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 us call for quired.;in )tions. Complete drawing on reverse side. ' " / Title: �L� Date: X Signed —� 13 FOR DEPARTMENT USE ONLY Application Accepted by Date Area �( Pit or Grout Inspection by Date Final Inspection by nlDate 44LV u Additional Comments: d ' ❑ Stk 466781 ❑ Lodi 369-3621 ❑ Manteca-,823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 55201 r if FEE INFO -� AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT:NO. 1 I +EH 13-24{REV-1/e 51 ,, Lain EH 14-26 ' OO v