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i? APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I� 1601 E. HAZEL T ON AVE:, STOCKTON, CA �p 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 i r 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. Job Address DPCity Lot Size PM � l 9W - Owner's Name Address —�+ ': phos 'Bnntractor- - re55' � — —License'No:l u�t�"" v__Phone'99'- I TYPE OF WELL/PUMP: ` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ I 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 Open Bottom 0anteca 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 1 Repair Work Done E Type of Pump H.P. State Work Done t ►Well Destruction ❑ Well"Diameter— — - ---�•LSealing Material (top 501 � Depth Filler Material(Belo r)- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is Q " \4 Iavai ble ithin 00 feet.I Installation will serve: Residence Commercial_ Other JsJL C ' ! Number of living units: Number of bedrooms Character of soil to!a depth of 3 feet: > - - �- Water table depth Q SEPTIC TANK El Type/Mfg No. Compartments PKG. TREATMENTPLT. ❑ b" w ! „ x„, '. Method of Disposal = � Distance to nearest: W I Foundatiow # Property Lineit r LEACHING LINE r L�No. & Length of lies n ,` ' Total length/size FILTER BED EDDistance tp nearest: ell�._ Fo ndatior Property Line .. SEEPAGE PITS ❑ Depth ��-' Size _V. �' Number SUMPS ❑ Distance to nearest: Well bun ions r Property Line "DISPOSAL PONDS ❑ 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., 1 c' 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 I 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 permif-isAsued,I shall employ persons subject to workman's compensa- tion laws of California." ,The applican must call fo all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR PARTMENT USE ONLY-1 t � Application Accepted by # Date -Area , 1 tt� a -� I - Z �#Pit or Grout Inspection by �i -- Date Final Inspection b Qat �- Additional Comments: ❑ Stk 466-6781 ❑ Lodi; 369-3621 ❑ Manteca 823-7104' i ❑ Tracy 835-6385 ` Applicant- Return all copies for Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE yam. INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•'NO. ` + EH 1}24{REV. EH 1429 Y {l!