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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 (Complete in Triplicate) ApplicationV is he�eb 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 o1 the San'Joaquin Local Health District, `2 Job Address O( �,Q 15P LZI ` ,2 C� City X Lot Size PM Owner's Name A �LTI� ✓ Address `Q f Phone Contractor •�?3L Address f License N1�/ EJ Phone TYPE OF WELL/PUMP: NEW WE( WELL REPLACEMENT L DESTRUCTION ❑ PUMP INSTALLA"TIO SYSTEM REPAIR OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL —PITS/SUMPS INTENDED USE ?TYPE OF WELL PROBLEM AREA CON STRUCTION'SPECIFICATIONS ❑ Industrial �j Open.Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,� + ® ' XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications v 1'1 Public 71 Other ❑ Delta Depth of Grout Seal Type of Grout —. k I Irrigation _.Approx. Depth i 1 Eastern Surface Seal Installed by 1 - r s H.P. State Work Done- TA Repair Work Done � Type of Pul.mp Well Destruction ❑ Well Diameter Sealing Material (top 501 d Depth 1 t Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1``'REPA1R/ADDITION i l DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ''4 Commercial_; Other E i Number of living.units:.. Numberr of-bedrooms ,-v w __„ Y..T_ Character of soil to a depth of 3 feet: Water table depth I Capacity No. Compartments x SEPTIC TANK ❑ Type/Mfg r PKG. TREATMENT PLT. ❑ r1 rtMethod of;Di'sposal-mi- . s Distance to nearest: Well Foundation I Property Line N ^` ' 1 >. I Total length/size :,LEACHING=LINE ;❑. No. & t}ngth of lines._ FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line + SEEPAGE PITS 11 Depth I Size I Number r SUMPS i-1 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 I)s, and rules and regulations of the San Joaquin Local Heal(h District. r i Home owner or licensed agent's signature certifies,ttie_tollowing: "I certify that.in the performance of the work for which this permit is issued;'1.shait 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 1 certifies the following: ''I certify that in the performance of the work for which this permit is11issued,t shall employ persons subject to workman's compensa- tion laws of California." t I The applicant t call f r all requitO ins tions. Complete drawing on reverse side. Signed X Title: Date- FOR 4 M k FOR DEPARTMENT USE ONLY . I Application Accepted by Date. Area ( Pit or Grout Inspection b Date Final Inspection by ,} j 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.O. Box 2009, Stk., CA 95241 r FEE AMOUNT DUE AMOUNT REMITTEDCASH SECEIVED BY DATE PERMIT"NO. INFO +, + EH 13-241REV.1/R 57 EH 14-211