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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT :5 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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.. I {� Job Address z -30 J) I E' ,� � C City /`F't Lot Size "�-�1'M Owner's Name V U Address Phone 1_ oCL ►�License No. Phone 9— Contracar 1� �-� Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTir' DESTRUCTION ❑ f PUMP INSTALLATION L]' SYSTEM REPAIR,C OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE I 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 SpecHicatians F] Public Cl Other ❑ Delta Deptfl of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth I I EasternSurface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter '� �_ Sealing Material {top 501 w Depth F Filler Material !Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATIONE_PAIRIADDITION l I DESTRUCTION t I.(No septic system permitted if public sewer is t L� �r available within 200 feet.) W Installation will serve: Re idence— Commercial _—Other- " Number of living units: Number of bedrooms `— Charac ter of soil to a depth of 3 feet: Water table depth SEPTIC TANK N--fiype/Mfg I Capacity �� No. Compartments PKG. TREATMENT PLT. ❑ D L C Cpr_J C Method of Disposal �r Distance to nearest: Welk/z Z foundation O Property Line 41 ?D 4 ` 1 LEACHING LINE Length of linestal lengthlsize FILTER iIED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS �apth Size Number SUMPS- r Cl Distance to nearest: WeII Foundation. Property Property Line DISPOSAL PONDS * ❑ t =a 1_2 i -1 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: "1 certify that in the performance of the`work for which this permit is issued, I shall not employ any personin-such manner-as-to-become-subject.to workman's compensatiM laws of California."'Contractor's hiring or sub-contracting signature certi ' the following: "I certify,that in the pertofmance,of-the work.for which this permit is issued, I shall employ persons subject to workman's compensa- tion av s California _ t The applica t s 1,60 for all s. C m drawing on re &a side. ° 1; 5gn T{A r tle: (/ Date: FOR DEP ` V RT T SE� ONLY !3{ k Application Accepted by ! Date `.r "V Area 2- �it r Grout Inspection by Bate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-A04 ❑ Tracy 635-6385 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 CASH RECEIVED 9y DATE ' PERMIT'NO. ou +.EH 13-24 1 REV.I/A s5 EH 14-28 c _ _