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APPLICATIOWFOR PERMIT F SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROMDATE ISSUED i (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. a/L�7y� "=rv3�ii 1Q Job Address _ - O�S 4� — City C Lot Size 1�� PM Owner's Name Address 7 ` "`' 'aai' Phone VV — Contractor's Name lawLicense No. 30572.1 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 r r`¢ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications IF ❑ Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout It ❑ 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') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is -_!o available within 200 feet.) Installation will serve: Residence &""Commercial_ Other Number of living units: �_ Number,kof b rooms I Character of.;soil to a depth of 3 feet: Water table depth SEPTIC,TANK .❑ Type/full Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal p - Distance to,nearest:' Well 4 +— Foundation ( Property Line l f LEACHING LINE [�No. & Length of lines G{1A/ Total length/size O I FILTER BED ❑ Distance to nearest: Foundation Property Line t SEEPAGE PITS Depth 1 I Size Number SUMPS ❑ Distance to nearest: Well-r4W Foundation gAP0 Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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."Contractors hiring"or sub contracting signature certifies the fallowing:"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 0 for I q red inspections. Complete drawing on reverse side. Signed Title: 0 Date: FOR DEPARTMENT USE ONLY �v_�— 1 Application Accepted by DatArea Q ate final Inspection b Pit Grout Inspection by w yDate all � Additional Comments: # ❑ Stk 466-6781 ❑ Lodi 369-3621' ❑ Manteca 823-7104 ❑ Tracy 836 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO i + EH 13-241REV.10/831 EH 14-28 Q