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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.} � _� Job Address (� } D, E. � 0� ' +1-d City Lot Size PM Owner's Name VQAddress a� � � "�� Phone ContracE �[ �0 Address Q&Y,� (X.0 , License No Z Phone TYPE OF WELL/PUMP: NEW WELL ❑' x WELL REPLACEMENT CJ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LJ 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing © Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public F1 Other I_} Delta Depth of Grout Seal Type of Grout i I Irrigation �Approx. Depth 12 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 06 Well Destruction 0 Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is fi available within 200 feet.) Installation will serve: Residence Commercial__ Other Number of living units: Numberedroot� l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ILS' Type/Mfgqk� Capacity ZIP No. Compartments PKG. TREATMENT PLT. ❑ • f ( ( Method of Disposal Distance to nearest: Well _�ow Foundation Property Line .._.- r LEACHING LINE No. & Length of lines C Total length/size FILTER BED ❑ Distance to nearest: Well S'0` Foundation Zy r Property Line fl SEEPAGE PITS 1fi-IDepth S Size Number SUMPS L Distance to nearest: Well.-_t00 foundation © r Property Line 5 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 JoaquiFi 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mu allZZ inspections. Complete drawing on reva all for side. Signed X Title: __ �� Date: FOR DEPAR MENT USE ONLY l Application Accepted by Date ePi f Area / or Grout Inspection by Date,— Final Inspection f�r Date< - s Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 1335-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201CK It FEE INFO AMOUNT D,�UE�� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 1324(REV.I/K 5: O utJ 3 S` t J� EN 14-M