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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Dist rict. � /� A Job Address r /Vi r J�r �' a � i�e��7 j 4 em City • Lot Size PITA �� 8 � � ��rr Owner's Name Address 5 ( )Lf 0 CA . yy Cyry t� p }y y//� r Phone 0 Contractor Y f' Address L_� U(7�l%ay�f >',�}�� /1r+ License No."r"12�Z Phoneglb s 61—Ift 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 ❑ Industrial " ❑ Open Bottom "c Manteca -Dia. of Well Excavation Dia hof Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ TracyType of Casing rG Specifications LJ Public Other Ll Delta `Depth of Grout Seal b Type of GrZin— M w om ❑ Irrigation 12Approx. Depth ❑ Eastern Surface Seal Installed by e, $ SCS Repair Work Done ❑ Type of Pump H.P. ' State,Work Done Well Destruction ❑ Well Diameter .c Sealing Material [top 5011, A,'1y{ Depth_._30 fk Filler Material i Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADbITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 3 a available within 204 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 Q Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ / 1 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 fb 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 .r The applica must call for all e i ions. Complete drawing an reverse side. Signed X TitleDate: OR P 14 SE ONLY Application Accepted b Date Are _ Pit or Grout Inspe y Date Final Inspection Date3 . t r Additional Commen ,'Stk 466-6781 ❑ Lodi 369-361 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95241 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. � + EH 13-24(REV. /H 51 EH 14-28 ✓ /C/ (ori�!/ �L/