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i -° 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 HealthDistrict. Q/ 1 1 f pry / 19 11C I Z PM Jab Addressf �F1 �l�i �� r City Loi Size Owner's Name Address -_S..YNY� Phone Contractor's Name Lcense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ~ PUMP INSTALLATION El 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout \\ ❑ Irrigation __Approx..Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of PumR H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth r Filler Material I(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/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 91--Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Dis osal + Distance to nearest: Well Foundation_.�_Q— Property Line LEACHING LINE QI�o. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I V_,4) pth 5_Size Number SUMPS i , ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS'` ❑ ; I15V wze � hereby certify that I have prepared this application and that the work will be done in accordance with San Jo uin 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 cerFifi the following:"I e Qy that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws a alifornia." The applica m II for all r wired i pecti s. C rawing on r verse sid Signe itle:f Date: (f FOR DEPAR ENT USE ONLY Application Accepted by _ Date ��► rea Q / Pit or Grout--ins jon by Date Final Inspection by Date . Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED SY DATE PERMIT"NO. INFO CASH +'EH 13-24IREV.10/831Its EH 14-28 f]r�