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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Now A Nru owANr Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T (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 , oldAtao eso _ City. Lot Size PM Owner's Name . `� �!� Address Phone Contractor [ f '� Address 6-ec License No q6 160 Phone. 5� 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I-I Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by _ J Repair Work Done ❑ Type of Pump H.P. State Work Done l i Well Destruction ❑ Well Diameter Sealing Material {top 50'1 _V Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) r 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 Property Line LEACHING LINE Cl No. & Length of tines - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 Ii gent'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 pars n i m or as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the foll i 'I e y hat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca f i ' The applicant of quired inspections. Complete drawingi se side. Signed X Title: Date: EPARTMENT USE ONLY ,Q Application Accepted by Date 3, V Area Z13 Pit or Grout Inspectio �Lodi �Dato Final Inspection by"�� LC / Date Additional Comments. ❑ Stk 466-6781 369-3621 ca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l 1NE0 AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. + H 13-241REV. E EH 14-2e �hJ