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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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/of 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. Q3 vQ t Job Address LA4e _ate ►'SeF q City Lot Size PM et%) _A,4 .QL� Address.7 '' gS Phone Owner's Nam �1 � Contractor Address O 330 License No.t06 Phone 12_Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION AJC SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES q"' DISPOSAL FLO. PROP. LINE I 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 omesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing' Specifications r7 Public ❑ Other ❑ Delta Depth of Grout Seal•. — '� Type of Grout _ I 1 Irrigation _-Approx. Depth I I Eastern //!� Surface Seal Installed by Repair Work Done ❑ Type of Pump..4C.t� H.P.Y� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') - -- TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l 1 OESTRUCTION I 1 (No septic system permitted if public sewer is w available within 200 feet.) q 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-L- No. Compartments PKG, TREATMENT PLT. ❑ f{ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No_ & Length of lines Total length/size T FILTER BED ❑ Distance to nearest: Well E Foundation Property Line SEEPAGE PITS I I Depth -- Size _ Number SUMPS LI Distance to nearest: ^!Weil 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. Home owner of 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." d The applicant must a II for all required inspections. Complete drawing on reverse side.' Signed X Title. Date: R DEPARTMENT USE ONLY 1 Application Accepted by Awl11;41 � Date `• Area Pit or Grout Inspection by t Date Final Inspection by Date Z ZQ r 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi a 369-3621 ❑ Manteca 823-7104 L1 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permi f/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 R_ ' a JJ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. I INFO CASH + EH13-24 IREV.I/H 5) 3� EH 14-M 2is D �1