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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. Job Address3 S .�/�G-�iL�L� � City R14C _ Lot Size PM Owner's Name Address 1Z Phone �! Contractor L Address 0 I Ci/4 License No,AwlPhone TYPE OF WELL/PUMP: NEW WELL O' WELL REPLACEMENT ❑ DESTRUCTION El 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 ED Domestic/Private ❑ Gravel Pack ❑ Tracy r Type'of Casing Specifications ❑ Public ❑ Other ❑ Delta _ _Depth of Grout Seal Type of Grout O ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 r _1 Depth Filler Material (Below 50') ria V" TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence Af!< Commercial— Other Number of living units: --I-- Number of bedrooms Character of soil to a depth of 3 feet: 04Dn Water table depth SEPTIC TANK ❑ Type/Mfg �i Capacity,' tr-O No. Compartments PKG. TREATMENT PLT. Ll F _ 9, f�` Method of Disposal Distance to nearest: Well Foundation_,7- "b Property Line 7_4:�_ ff� ; LEACHING LINE ❑ No. & Length of lines X / Tota AN '/size S FILTER BED ❑ Dista ce to nearest: We I /al:? _ Foundation � `Property Line 6vw SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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. 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."Contractor'shiring 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 call for II requir d inspections. Complete drawing on ieverse side. Signed,X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: ►^ f- f� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy&635-13Wa Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH 1 -241AEV.tixsl EH 1429 / / p+f R& —" —7"T