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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Address it C%�.79 21 4 9LW / , City Lot Size PM �Q �21►�i9�r1 s v�Rr�=-R �yS. �ezo /r1Cox aA� X67_/—q_3— Contractor's ontractvr Address �/V � License No. /___ _ _ _ _Phone 3 Contractor's Name f a! -a License No._J� zZ ��' _ Phone TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT. ❑ DESTRUCTION ❑ PERMIT `NO. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50.1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is / available within 200 feet.! Installation will serve: Residence p Commercial _ Other Number of living units: __._./__ Number of bedrooms _3 Character of soil to a depth f 3 feet: Water table depth A-7 SEPTIC TANK Type/Mfg c Capacity � No. Compartments 12 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well f —Foundation ". f 'Property Line LEACHING LINE le No. & Length of lines Total length/size f�D v2 FILTER BED ❑ Distance to nearest: Well1� Foundation Property Line a� SEEPAGE PITS Ll Depth Size dJ Number . 3 _ SUMPS I 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 T e 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 -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 mus :Gail for all required i pections. Complete drawing on reverse side. Signed P Title: Date: _L ` FOR DEPARTMENT USE ONLY Application Accepted by Date /65 z Area F Pit or Grout Inspection by Date Final Inspection by Date /e �Sa Additional Comments: ❑ Stk 466-6761 ❑ 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 + EH 13-24 (REV. 10183) EH 1428 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT `NO. S. �o a 10� � 534-'13 577