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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 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 I yn.7-00City Lot Size P t Owner's Name 4Phon Contractor [ldress License No. hone 31 00'P TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Industrial [I Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I&T REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l d Installation will serve: Residence—1 Commercial_ Other Number of living units: 1 Number of bedroom Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg —� 0`; Capacity (2 No. Compartments PKG. TREATMENT PLT. ❑ V Method of Disposal Distance to nearest: Well `� f=oundation 140 Property Line,S70 LEACHING LINE ❑ No- & Length of lines "'~ Total length/size FILTER BED ❑ Distance e `to nearest Well�Q� Foundation Property Line SEEPAGE PITS I I Depth JtJ Number UM7PS L❑ Distance to nearest: Well Foundation Property Line ISB POSAL PONDS ❑ 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 f all re i d nspections. m to drawing on er a side. Signed X Title: Date: Aq AV FOR DEPARTMENT USE ONLY / Appii on Accepted by d Date Area r rout ItYs�ion by Date�[ �i Final Inspection by Date.��(L Additional Comments: a- ? ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Vanteca 823.715i Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 1324(REV.tiKst 77c, EH 11-28