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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 Address ��p / �O y'?�/9,/ �': City T�'ltGy 'Lot Size PM Owner's Name 6xig'A y Address Phone 1 Contractor ! /�A*VAO r.. scut Address License No. Y07-,* / Phone TYPE OF WELLI'PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I 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 r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout- #f ❑ Irrigation ---Approx. Depth ❑ Eastern' Surface Seal Installed by Repair Work Done ❑ Type of Pump j H.P.•_ _: State Work Done Well Y]estrucJion.� �O Well Diameter Sealing Material (top 50') ! t ' 4 ! Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) € i Installation will serve Residence_ Commercial T Other Number of living units: Number of bedrooms Character of soil to a?depth of 3 feet:--�-S��y ��A�i--- — -^-- Water table depth a SEPTIC TANK ❑ Type/Mfg j Capacity 1 No' Compartments PKG. TREATMENT PLT. ❑ ) Method of Disposal t Distance to nearest: Well Ado Foundation a Property Li+'ne LEACHING LINE ❑ No. & Length of lines a Total length/size FILTER BED ly Distance to nearest: Well Foundation r I Property'Line ,' ,. I .._._ SEEPAGE PITS ❑ Depth Size Number �r k T k 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's hiring or sub=dontracting 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 wotkrnain's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. + Signed X aF Title: Date: ' FOR DEPARTMENT USE ONLYr Application Accepted by ? lP/• Date Area k+� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521' ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton'Ave., P.O. Boz 2009, Stk., CA 95201 t "FEE "-"AMOUNT buE- _ AM0t1NT REMITTED CK —RECEIVED BY DATE PERMIT`NO. .INFO CASH +.EH13-24(REV.s/a5) � q73 J EH 1426 ! i - ... ._.