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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. � / / �7p Job Address I i�17 M� �a(� �"�✓2m��T°!+(/ City 4i`1 W Lot Size �.� PM Owner's Name f J/n/ (, Address �� i Phone W %'-�-rte Conttactor Addres icense No.�S �i�� Phone 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 PITSISUMPS INTENDED USE TYPE OF WELL PROBJ!EM AREA CONSTRUCTION SPECIFICATIONS \ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public i l Other f] Delta Depth of Grout Seal Type of Grout — I I irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Dane _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 �. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence= Commerc Other Number of living units: P4 Number of bedrooms "At n Character of soil to a depth of 3 feet- Water table depth ` SEPTIC TANK Qra��`❑ Type/Mfg Capacity No- Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size AL0f f Number SUMPS ❑ Distance to nearest: Well Fou'ildation / � Property Line -4ryf DISPOSAL PONDS ❑ 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. ' j... 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." Contractors 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." The applicant must tail for all required ins cti ns. Complete drawing on reverse side. Signed Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Date Area 'Pit or Grout Inspection by A Date , Final Inspection b Date Additional Comments: ^ / ` , ❑ Stk 466.6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Kracy 5-6385 ` 00� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. ox 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. ♦ EH 13-24{REV.111151 ! �. �^'� -- Z " ,2347s- EH 14-2e