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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/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. lt Job Address r4 City t 0 J ( Lot Size PM Owner's Name �a-(�-!T_ Address / z,, 4J/e 4�� Phone Contractor V,2 ch " Address License N0.2992 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATIO J SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _Ze SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION - 410 AGRICULTURE WELL OTHER WELL` PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrialpen Bottom ❑ Manteca Dia. of Well Excavation_f Dia. of Well Casing 54omestic/Pfivate ❑ Gravel Pack ❑ Tracy Type of Casing L'G Specifications/p M i Public f i Other Cl Delta Depth of Grout Sea r Tyne rou#� ,.Cs I I Irtigation r3�.-��.-Approx. Depth 11_1 Eastern rfac Seal Installed by t _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Weil Diameter _-_ Sealing Material (top 50') [, Depth Filler Material Below 501 "TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIR/ADDITION I I DESTRUCTION ! 1 (No septic system permitted if public sewer is available within 200 feet.) \^ Installation will serve: Residence_ Commercial_ Other vl 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L7 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. \� 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 applicant must call for all requi edinspe tions. Complete drawing on reverse side. Signed X .� Title: Date: FOR DEPARTMENT USE ONLY Applic n Accepted by Datepow! ea_I'- Pit Grp Inspection by Date 3! g Final Inspection by Date.... Additional Comments: C ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy •835-6385 :Applicant-'Return all copies to: Environmental Health Permit/Services 1601 E.'Hazeltori Ave., P.O. Box 2009, Stk., CA 95201 FEE INFOk AMOUNT DUE AMOUNT REMITTED CK it- CASH RECEIVED BY DATE P£GRMIT'NO. + EH 13.24(REV.1/851 / .f !� � V !-/�/� EN 14-2e (!J 7 p_