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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. �J Job Address �5 /C ��.� 9/ it A/ leQ - � City 5Lot Size PM Owner's Name &44 Address Phone a 3309/ Conlractor/ .4� 5 Address G/J. Q,1—_ liLicense No. �r&-: Phone, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION � jf„I SSY TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWEMfxDISPOSAL 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 Et-bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications- i-1 Public I-] Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth l I Eastern Surfs a Seal Installed by Repair Work Done ❑ Type of Purnp3 H.P. ;_7 State Work Donet .��/�J Well Destruction ❑ Well Diameter Sealing Material (top 50') TA.�g f,93 Depth Filler Material ?Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _Number of bedrooms _ ML Character of soil to a depth of 3 feet: �n_ Y Water table depth 64 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _PKG, TREATMENT PLT, ❑ T � _ _ T Method of Disposal ti 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 11 Depth > Size Number SUMPS L� Distance to nearest: Well I Foundation Property Line DISPOSAL PONDS ❑ I 1 I hereby certify that I have prepared this application and that,tfle_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 su6iect 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." k The applicant for rs�II required i pections. Complete drawing on re� e. Signed X—�� Rt./ - +Ti Date: F R DEPARTMENT USE ONLY Application Accepted by Date f �r Area #r Pit or Grout Inspection by Data Final Inspection by Date_i V/r M Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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 FEE INFO AMOUNT DUE A NT EMITTED CASH RECEIVED BY PATE PERMIT'NO. r.EH 13-24(REV.I/n 5) � � EH 14-26