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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 District. ��j��r, Job Addressr �/ �dLI_ � _TJT— City of Size PM + Owner's Name Address _ �-'��'/� _ Phone Contractor's Name 11dLicense No. Z, 5 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 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 Pump H.P. State Work Done h Well Destruction ❑ Well Diameter Sealing Material (tap 50') Depth Filler Material (Below 501 41 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTI (No septic system permitted if public sewer is �- available within 200 feet.) Installation will serve: Residence_ Commercial_ Other F Number of living units: Number of bedrooms ( /} Grharaicter of soil,to a depth of 3 feet: Water table depth 1 SEPTIG�TANC ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT, PLT. El Method of Disposal # Dista ce to nearest: Wel Foundation _ Property Line LEACHING LINE ❑ No. & Length of lines11 4-1111114111110 Total length/size (� FILTER BED 11Distance to nearest: I Well Foundation _ Property Line l} /0- P j �L SEEPAGE PITS Depth '00� Size Number SUMPS ❑ Distance to nearest: %a Well Foundation Property Line DISPOSAL PONDS ❑ "`� I hereby certify that I have prepared this application and thatthb wo"rlt-will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations'of the San Joaquin Local Health District. Holne,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 performnce of the work for which this Perm*it is issued, I shall employ persons subject to workman's compensa- tion.iiii 6 f Califor ia." The•appjiant m c Ilr an require cfi s. plate drawing on erse side. Signed Title:. Data: d - OFO EPAARTMENT USI ONLY 0 30-d Application Accepted by - Date Area _ Pit or Grout Inspection by Date (� (� Final Inspection by Date Additional Comments: W °(� "'��+• .�6E�-� '_- + --_ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 ,,meq FEE INFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT•`NO. + 15H1 3-24 IREV.10183) Eli 14-26