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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 , 1. W, (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.: .h '.- Job Address t City r Lot Size ��r X �� ,PM Owner's Name L,. 0 u 1,1-- Sl l l e,Address � 3 5� � L C� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �tDISTANCE TO NEAREST: SEPTIC TANK S LINES DD SPCrAL FLD. PROP. LINE + n FOUNDATION AGRICU URE WELL —_,,--OTHER WELL PITS/SUMPS 11 INTENDED USE TYPE OF WELL PROBLEM AREA STRUCf9 SPECIFICATIONS ❑ Industrial 0-Open Bottom ❑ Manteca Dia;, `1Nell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of ing Specfications ❑ Public ❑ Other ❑ Delta Depth of Gro Seal Type of Grout ❑ Irrigation g _...__4pprox. Depth ❑ Eastern ,, 4. Surface Seal Inst ed by Repair Work Done E] Type of Pump ! H.P. .` State Work Done 5 Well Destruction ❑ Well Diameter Sealing Material (top 501 {}� DepthFiller Material'{Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONk (No septic system permitted if public sewer is ' # available within 200 feet.) Installation will serve: Residence Commercial— Other i Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. Cl ,._. –_; Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ :Distance to nearest: Well. Foundation Property Line 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. -' Homeowner or licensed agents signature certifies the.-following: "I certify that in the performance of the work for which this permit is issued, I shall not } dmploy any person in such manner as to become subject to workman's oompensafion laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed )� Title: l� "`•SAS Date: ` Y 7 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by /� ` _ Date-3–P-7—P Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 835-6385 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'BY DATE PERMIT'NO, + EK 3-24 1REV.1/a5] EM 14-24 ^� 11 7 cl=)� `y f