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kg .- k, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA n►'l) 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 cy � City af^' Lot Size PM Owner's Name f \s�ftJ L/�- �� Address 15 6lD ( J d1 ' Phone �5 Contraci . Address� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ { 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 I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ; Dia. of Well Casing {� Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications "1 I"1 Public F Other ❑ Delta Depth of Grout Seal Type of Grout-- k\ I I Irrigation —"Approx.I Depth { I Eastern Surface Seal Installed by _ Repair Work Done 1 ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ftops 50') _ Depth Filler Material (Below 50') -� TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION I (No septic system permitted if public sewer is f available within 200 feet) F 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/Mfgt` Capacity No. Compartments PKG. TREATMENT PLT- ❑ 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 I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS _n 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 subcontracting 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 must c Il fo ctions. Complete drawing on reverse side. ) Q g Signed X Title:rDate: 0 U F DEPARTMENT USE ONLY Application Accepted by ` Date 3~1 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: / ��`-� 71 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 EK 1426IAEV. /nsl 35,6 C�i • - ~�l ! �:r