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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 a� PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) w �� 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. I y� 1—ntractor' Address [ �p �`��p pp, City � Lot Size PM ner's Name ®$k�1� LJ�TSm� Address F 17 � /' �� Phone r a.2- !672' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI E9-SAtrFClY ~ PROP. LINE FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottomanteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel P D.Tracy Type of Casing Specifications f`1 Public er Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _,Approx. Depth I I Eastern Surface Seal Installed by Repair one ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 .A Depth Filler Material (Below 501 [� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ) DESTRUCTIO No septic system permitted if public sewer is (1' vailable within 200 feet-) 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 ❑ T ype/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line L SEEPAGE PITS" I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property 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. Homeowner 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 nota employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signatui 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 must call for all re fired inspections. Complete drawing on reverse side. SignedX Title: © I'y&J Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by toJ' Final Inspection by• / G� Date Additional Comments: © er _ ^ ❑ Stk 466-6781 ❑ Loi 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 INFO AMOUNT DUE AMOUNT REMITTED L CK CAS 1 RECEIVED BY DATE �PPERRMIT'NO. +.EH13-24 IAEV. /x 51 ~ 4X0 EH 14-29