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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) r 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. 5O �.. 1 Cit - Job Address Y Lot Size bra Y d� of r Owner's NameAH { "` d [ w Phone Contrac t Address o 7 License No.32D `Z _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE r _ FOUNDATION- AGRICULTURE WELL OTHER WELL-� - — PITS/SUMPS _ v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Iridustrial I" ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack © Tracy Type of Casing Specifications �� f'1 Public f-1 Other Cl Delta Depth of Grout Seal Type of Grout-- I rout -_I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done n Type of Pump H.P. State Work Done _ Well Destruction © Well Diameter Sealing Material [top 501 Depth r Material (Below 50') TYPE OF SEPTIC WORK: 'NEW INSTALLATION f I EPA( DDITIO DESTRUCTION ! I (No septic system permitted if public sewer is 4y. available within 200 feet.) Installation will serve: -Residence Commercial Other Number of living units: r Number ofAn edrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 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 P FILTER BED ❑ Distance to nearest: Well Foundation Property Line ! SEEPAGE PITS ><Depth Size rNumber l v SUMPS ❑ Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS -EJ 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 Di%trict. 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 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 taws YfCalifornia." The applican ust call for qu' d inspections. Complete drawing on reverse Sid Signed X Title: _ 1� R Date: I FOR DEP RTMENT USE ONLY �1 Application Accepted by Date r Area/J' ,L � it Grout Inspection by ate ��d Final Inspection by 7� G4-*oDate Additional Comments: ❑ 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 AMOUNT DUE AMOUNT REMITTED CK 40 CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 13-24(REV.t i k 57 T � EH 14-28 .�� CL� h �- L !� �� [ „�•T� 1