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APPLICATION FOR PERMIT SAN JOAQUIN. LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone 12091 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address City r�� Lot Size t. X/T0 PM Owner's Name Address - Phone " f ContractorAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUM NSTA-LLATION"❑ SYSTEM REPAIR EIE]OTHER DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing W p cifications ❑ Publict =-_-❑-Other ❑ Delta Depth of-Grout Seal Type of Grout r El Irrigation ---Approx.Depth ❑ Eastern Surface,Seal Installed by Repair Work Done r ❑ Type of Pump f t H.P. E State Work Done Well Destruction a ❑ Well Diameter I I Sealing Material (top 50') Depth € Filler Material (Ballow 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ I REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is + available within 200 feet./ 1 Installation will serve: Residence— Commercial_ Other Number of living units"-'^" "" Number of bedrooms r � Character of soil to a depth of 3 feet: t Water table depth SEPTICTANK r ❑ Type/Mfg _ Y. } Capacity No. Compartments ! PKG.,TREATMENT PLT. 11Method of Disposal k Distance to nearest: Well Foundation Property Line LEACHING LINE fi ❑ No:& Length of lines 1 Total length/sizes f �tft jWell j FILTER BED F1Distance to nearest': Well F - Foundation Property Line. ' SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line s DISPOSAL PONDS ❑ r f I hereby certify that I have prepared this application and that the work will be done in accordance,wlth 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." { , t [ The applicant must call for all r quired inspections. Complete drawing on reverse side. i 1 l ! s . l'l 00 Date: o�- gyp• I Signed FOR DEPARTMENT USE ONLY _ Application Acceptf Sd by VAS .�`C.r� - Date 'mow 1Area� � � q Pit or Grout Inspection by Date Final Inspection by Date �! Additional Comments: ❑ Stk 466-6781 , ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCIL# RECEIVED BY DATE PERMIT`NO. INFO ._ a ��.... ,.q —_ I:R 33 + EH 13-24(REV.i/s51 - —10- / i EH 14-26