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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 d PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. I (Complete in Triplicate) �i 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 f Local Health District, y Job Address Z 17 V�� .AA Ci i,,K,' �� Lot Size Z&-C�i'1 ' PM Owner'sArNae Address �= Phonerr22 Contracta" Address9hik 7b 7 License No. 3z�2.L Phone I TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST-ASEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE s TYPE-OF-WELL -PROBLEM AREA—CONSTRUCTION•SPECIFiCATIONS R.. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ; ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane 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 ,/ available within 200 feet.) Installation will serve: Residence� Commercial - Other" Number of living units: —/_ Number of bedr oms t/� 7 Character of soil to a depth�f 3 feet: Water table depth SEPTIC TANK a°r Type/Mfg 4iu,6 Capacity l _ No. Compartments PKG. TREATMENT PLT. ❑ / f Method of Disposal r. Distance to nearest: yWell Foundation Property Line LEACHING LINE 11 No. & Length of lines g +� Total length/site 14- ti lT FILTER BED ❑ Distance4o nearest:. Well_ Foundation .. IT Property Line c, SEEPAGE PITS ❑ Depth r Size Number ' SUMPS' ❑ 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 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 app Ica must call f II rerluired inspections. Complete drawing on reverse Sid . a Signed �U Title:��. Date: �- FOR DEPARTMENT USE ONLY '— Application Accepted by Date Are Pit or Grout Inspection by Date Final Inspection by 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.Q. Box 2009, Stk., CA 95201 FEE I CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. + EH13-24/REV,1/e sl Q EH 14-28 i