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APPLICATION FOR PERMIT rSAN JOAQUIN LOCAL HEALTH DISTRICT f/ 1601 E. HAZE T ON AVE., STOCKTON, CA 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. resL r Job Address f( ,¢(�) City Lot Size J A PM S &,y rJ11� Phone ^ �� Owner's Name Address //�J �(- //) 1 c /1,3/V 4:�;k4, ense I V 116 � �ContractorAddress 1L No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ YSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK WER L ES DISPOSAL FLD. PROP. LINE FOUNDATION A IC TURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom El Mantec Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other Cl Delt Depth of Grout Seal Type of Grout 11 Irrigation Approx. Depth I I Ea ern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H. State Work Done Well Destruction ❑ Well Diameter Se ing Material (top 501 pQ Depth Fille Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION l I DESTRUCTIO (Noilseptic system m rmittted if public sewer is 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/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well F nda' Property Line LEACHING LINE ❑ No. & Length of nes Total length/size FILTER BED O Distance to nearest: Well F undation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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.Diltrict. 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 applican ust call f required ' spections. Complete drawing on reverse side. c Signed X Title: _( ql�� Date: FOR DEPARTMENT USE ONLY Application Accepted by �1 — Date V ea Pit or Grout Inspection by Data Final Inspection ate Additional Comments: ❑ Stk 466-Ml ❑ Lodi 369-3621 D 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 CASH RECEIVED BY DATE PERMIT NO. INFO /T57- J I/!?I +.EH 13.24(REV.t i n 5) C., EH 14-28 lr�r— i —