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E APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT h 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. 19OX17� Job Address °►� City Lot Size PM Owner's Name _ ddress (Phone 79 i Contractor's Name ansa No. Phone f,,—J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-1PUMP INSTALLATION ❑ +SYS EM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWEW LINES` * DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL''L'�k OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA.,;�CONSTRUCTION_SP_ECIF-ICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing,_ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of-Casing Specifications ❑ Public ❑ Other ❑ Delta Dapth'of Grout Seal Type of Grout a ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ! State Work Doe l Well Destruction ❑ Well Diameter Sealing Material (top 501 fp Depth Filler Material (Below 501'`x"`"" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ly DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.! o Installation will serve: Residence— Commercial— Other -� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1E a` } ; Method`of Disposal Distance to nearest: Well 4' Foundation {Property Line LEACHING LINE " No. & Length of lines :' '` Total length/size M FILTER BED ❑ Distance to nearest: Wei I Foundation �'�' i Property Line { SEEPAGE PITS ❑ Depth ize Number ll► ---^"` SUMPS Distance to nearest: Well &AILI Foundation Property Line 410 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."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 us II f all re a inspections. Com late drawing on arse side. Signed Title: /! z I-- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Dat Final Inspection b ate Additional Comments: 6*6 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 I IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.101831 Co �>I�-7 g}I $IJ-7 �V EH 1428