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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 456-6781 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 Rules and Regulations of the San Joaquin l Local Health District. S ,rL �r, Job Address City - Lot Size 5.6 PM 1 Owner's Name G.�2��11_a AddressPhone 3 t� Contractor Address Z�>- License No. Phone 1 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 E) Domestic/Private LI Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public f] Other ❑ Delta Depth of Grout Seal Type of Grout N I I Irrigation _____Approx. Depth I 1 Eastern Surface Seal Installed by _ I i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 501 r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ( I DESTRUCTION 111No septic system permitted it public sewer is r available within 200 feet.) !I Installation will serve: Residence_ Commercial k Other U 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 (a ! Distance to nearest: Well _ Foundation Property Line LEACHING LINE No. & Length of fines Total length/size 4:4t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth (191F�11 _Size Number { SUMPS Ll Distance to nearest: Well Foundation Property Line 1. 8 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 3 rules and regulations of the San Joaquin Local Health District. r 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 applica ust call for a requi inspections. Complete drawing on reverse side. SignedX4 AWgq Title: �` 1f Date: FOR DEPARTMENT USE ONLY Application Accepted by Date l A� Area Z-1� I 1 Pit or Grout Inspection by Date Final Inspection by 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 RECEIVED BY DATE PERMIT NO. +.EH 13-24 tpEV.t/H 5) J -0( �r}r� yt{ �^' ,-O-