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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT t: 1601 E. HAZETON 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. q8 'g-c> v City Lot Size Job Address Owner's Name Al A,Q.. Address X&C"0 Phone Contractor A Address ..5-fo License rPhone TYPE OF WELL/PUMP:. NEW WELL.❑ , 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 ❑-lndustriaF m ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r Sp ecifications ❑`Dome'sticlPrivate } ❑ Gravel Pack -..-D.-Tracy Type of Casing -f 3 Public ' Cl Ocher # ;=].Delta t Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth 1 I Eastern. Surface Seal installed by Re aii-Work Doni ❑ Type of Pump —" H.P. State Work Done_ t Well Destruction ❑ Well Diameter Sealing Material (top 501 til Depth 'r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11' REPAIRIADDITIO I DESTRUCTION I I (No septic system permitted if public sewer is \J1, available within 200 feet.] Installation will serve: Residence_� _—Commercial -Other-- Number of living units: ' Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/MfgCapacity"" """ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 9 Distance to nearest: ,Well ' Foundation Property Line c' LEACHING LINE No. & Length of lines O /�7• Total length/size \ FILTER BED El Distance to nearest: Well f�� Foundation Q Property Line SEEPAGE PITS �fDepth �^� Size — c'" N u m b e r SUMPS DDistance to nearest 1 Well//�Q Foundation_7__R`=�Property.Line DISPOSAL PONDS 4 ❑ d th t the work be done in accordance with San Joaquin a county ordinances, state laws, d I hereby certify that t have prepared this application an 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 r tion laws of California." The app)' mus for all re ire ctions Complete drawing on reverse side. ff rC� Signed Title:�,, ¢ _ Date: F DEPARTMENT USE ONLY -� y.m �w 'Y W Application Accepted byCDL Date Area Pit or Grout Inspection by Date Final inspection by Date Additional Comments: 'K ❑ 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 I FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE P/EERMIT'NO.. INFO + EH 13-24IREV.IIH51 EH 14-28