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APPLICATION.FOR PERMITf SAN JOAQUIN LOCAL' HEALTH DISTRICT . 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED ., . .. - i, r + (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 arid'Regulations of the San Joaquin Local Health District. `,{ Job Address ❑r��►, j9�t,3 SSG ,� City Lot Size PM Owner's Name _ - AddressM—A / &IOME _ w Phone alp Contractor Address_j4T OO i�,i—R --016- 7'S License No.,.V2�M/ Phone 9/ TYPE OF WELL/PUMP:vNEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION ❑ N, i PUMP INSTALLATION ke SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r` DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA= ''CONSTRUCTION SPECIFICATIONS �1 I ❑ Industrial E.Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing +� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t- Specifications &"Public 0 Other ❑ belta, ,,_,,,,,,-Depth of Grout Seal V*—Type of Grout ❑ Irrigation _�__4pprox. Depth--'❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work DoneA Shia Well Destruction ❑ Well Diameter Sealing Material'itop 501 E 1 Depth Filler Material lgelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _" .; . V - available within 200 feet.) Installation will serve: Residence— Commercial_ 'Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: F Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length-of lines Total length/size FILTER'BED' ❑ Distance to nearest: Well I foundation Property Line SEEPAGE PITS 0 f Depth Number SUMPS ❑'� Distance to nearest:. Well Foundation• Property Line DISPOSAL PONDS C7 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 Joaquin Local Health District.i Home owner or licensed agent's signature certifies the following: "L certify that in the performance of the work for which this peimit is issued, I shall not employ any person in such manner as to'become subject to workmang-compensation.laws of California."Contractor's hiring or sub-contiacting 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 Con tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X - ff :Title: Date: FOR DEIPAJ3TMENT USE ONLY Application Accepted by r a Data Area - LJ Pit or Grout Inspection by ' � Date Final Inspection by Date � — Additional Comments: r� ❑ 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 FEEK INFO 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-N0. j '+ EH 13-24{REV.1/a57 3 5 . - ..�/ ��i EH 1426