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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 �E. HAZELTI ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t k 0 .. ".. (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 °n 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. ; t. r }t , Job Address �� 6°�J�"�' — --- City Lot Size PM Owner's Name Address Phone ContractQ � Address7� License No. �7`� Phan, TC- 05_ 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 ,t F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing. } 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t ❑ Public ' " `"❑ Other ,. 11-Delta Depth of Grout Seal Type of Grout �`- � " Surface Seal Installed by ❑ Irrigation- �pprox. Depth ❑ Eastern Repair Work Done ❑ Type of Pump H ... State Work Done Well Destruction ❑j Well Diameter Sealing Material(top 501 Depth filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INST)kLLATION- ""REPAIR ADDITION Er DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve:: Residence_ Commercial_ Other 1 Number of living units: Number of be ooms f Character of soil to a:depth of 3 feet: Water table depth yul SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ++ Wellr Foundation Property Line LEACHING LINE l A,—No. & Length.of lines �+ Total length/size Q K i < r s FILTER BED EDDistance to nearest: Well�5`C3 r Foundation //5 Property Line},�- f� SEEPAGE PITS l ❑ Depth �� Size k Number P SUMPS { E,-:Distance to nearest: Well 1420 Foundation' s Property Line S DISPOSAL PONDS ; ❑ i -- 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'orlicensed agent's signature certifies-the-following: 1-cetify 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,l shall-amploy-persons subject to workman's compensa- tion laws of California." r The applicant call for all quire inspections. Complete drawing on reverse id III _ Signed Title: Date: L Q �P r FOR DEP RTMENT USE ONLY �r A plication Accepted by Date / Area P,P PIF �` Date ��61:inal Inspection b Date Pith or{Groo[utInspection by Y. Additional Comments: ❑'Stk 466-6781 ❑ Lodi 369-3621 171 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMW NO. INFO CASH +EH 13-24 1REV.i/a51 r EH 14-28 l moi'