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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 � ,� .x (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 Address3s5,_3_ claon City Lot Size ` PM Owner's Name Address Phone Contrac Address_ 7/0 / c License NM_3; ZZ6 Phone AOS' 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 _ o INTENDED USE TYPE OF WELL PROBLEM'AA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i7 Public Cl Other Ll Delta Depth of Grout Seal Type of Grout _ € I Irrigation _.,Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ _ W TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is r/ available within 200 feet.) Installation will serve: Residence— Commercial_ ther Number of living units: / Number edroom UJ Character of soil to a depth of 3 feet: F Water table depth SEPTIC TANK 'x Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ( / Method of Disposal Distance to nearest: Well S, [ Foundation Property Line Q 113 / / / Q LEACHING LINE X No. & Length of fines ` Total length/size. Q x FILTER BED O Distance to nearest: Well Foundation 147 Property Line --,-- ! t! SEEPAGE PITS 1*:� Depth p?y� Size L Number T SUMPS Ll Distance to nearest: Well Foundation SCS Property Line DISPOSAL PONDS ❑ 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-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 t call for all uire inspections. Complete drawing on reverse�si e Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area G U aPit r Grout Inspection by Date Final Inspection Date dditional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 CK 1FEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. + EH 14-28(REV.1/19 5) { �