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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 l PERMIT EXPIRES TYEAR 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, I Job Address s � �G lr 5 City Lot Size _ A PM Owner's Name �Ayl Address 1-'I" �� - Phone qqa' rJ p�7 Contractor � Address � License No.��o.�Phone TYPE OFIWELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLA. 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 1r� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (f" Type F] Public ❑ Other F1 Delta Depth of Grout Seal T Vp of Grout--. r , I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done D Type of Pump ,,_H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 i Depth Filler Material (Below 50.1 — TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 'REPAIR/ADDITION I I" DESTRUCTION.JVINo septic system permitted if public sewer is r - F available within 200 feet.) Installation will serve. Residence_ Commercial Other Number of living units: Number of bedrooms y v Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type IMfg Capacity' f No. Compartments PKG, TREATMENT PLT- 17 Property of Disposal Distance to nearest: Well Foundation ) Property Line 4 t _ LEACHING LINE ❑ No. & Length of lines Total length/size rj FILTER BED i El Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS I I Depth Size Number , E SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I L1 '` - i 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 i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I '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 ust calt fo all required inspections. Complete drawing on reverse side. j t Signed X Title: Date: FOR DEPARTMENT USE ONLY kZIApplication Accepted by Date Area 9 I Pit or Grout Inspection b Date Final Inspection b Date ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 364-3621.,. _;v■ Manteca-823-.71 _❑.Tracy 835-6385______ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I � t i FEE AMOUNT DUE---- AMOUNT-REMITTED-------CK F---RECEIVED BY -- DATE PERMIT NO. INFO ♦ EH 13-24IREV.r/nbl �S V V t EH 14-26 k