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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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/p mp and the Rules and Regulations of the San Joaquin Local Health District. Job Address Lot Size /0 PM /f Q * Address.{�� ` Phone V\ O+nrner`s Name �� -Y - � ^% _.� 2 Contractor Address License No. Phone TYPE OF W LL/PUMP: ONEWWELL ❑ 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 El Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (r— r' -.�• V ff`Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications l ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 r ❑ Irrigation _—Approx: Depth ❑ Eastern Surface Seal Installed by n Repair Work Done ❑ Type of Pump H.P. State Work Done --! Well Destruction 0 ❑ Well Diameter Sealing Material (top 50') �� " Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. ❑: a �.� Method of Di $ Distance to nearest Well./D 0 Foundation Property Line i LEACHING LINE No. & Length of lines Tdt I length/size FILTER BED ❑ Distance to nearest: well Foundation !~ Property Line SEEPAGE PITS ❑ Depth Size Number f j SUMPS 1-1 Distance to nearest: Wek1 Foundation Property Line DISPOSAL PONDS ❑' • I hereby certify that I have prepared this application and that the work will be done ir+accordance with San Joaquin county ordinances, state laws, and rules and regulations of the SanJoaquin Local Health District. a 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."Contractors hiring or subcontracting signature .certifies-the,following: "I certify that in the performance of the work for which thisperntit is Issubd,1 shall employ persons subject to workman's compensa- tion laws of California." ` f f 4 1! The applica ust call for al re fired inspec'ons. Complete drawing on reverse side. �... Signed Title: l Date: 9 , r" F DEPARTMENT USE ONLY _. 3 - E - 4 Application Accepted by Date Area Pit or Grout Inspection by a Rate "Q? Final InspectioJi by Date -87 S. x Additidnal Comments: # ❑ Stk 466-6781 ❑ Lodi 369-3621 t` ` ❑ 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 IFEE ND AMOUNT DUE - AMOUNT REMITTED CASH RECEIVED BY _ t� T DATE Lg PEERM NEH'13-24IREV,i/05) Qt��.. F -_ - '��ll T�_q_1 1 EH 14-28 L