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APPLICATION FOR PERMIT r " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. _ . _ " . . j•. , J - .:— F. Job Address /,(1 � 'e-.0 City C Lot Size nc!;1 PM Owner's Name Address�fi�'Ae�.f/ Address Phone = Contractor 9 Address * License No. Vdifto Phone TYPE OF WELL/PUMP: NLOW WELL ❑ WELL REPLACEMENT'❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES W"DISPOSAL-FLD.'�, PROP. LINE 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 D Domestic/Private CD Gravel Pack El Tracy Type of Casing j Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1 Type of Grout g ❑ Irrigation i,... --Approx. Depth ❑ � Eastern Surface Seal Installed b PP P Y Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well diameter Sealing Material {top 501 ~' Depth i Filler Material(Below 501 1 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 bedrooms_ Character of soil to a depth of 3 feet: r4&C& Water table depth -3 Q SEPTIC TANK . ❑ Type/Mfg .fie• Capacity Z No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposale l Distance to nearest: Well Foundation,_.:J� Property Line " LEACHING LINE 4 No. & Length of lines Total length/size s - FILTER BED ❑ Distance to nearest: Well 574:� Foundation .2�C ,_._:Property Line SEEPAGE PITS ❑ Depth Size Number ' SUMPS lZ Distance to nearest: Well Foundation Foundation� Property Line DISPOSAL PONDS L1s •-A I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquirncounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District'^ "'""' "-" — '" """ ' - ' I 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." I F t The applicant ust call for all required inspec' ns. Complete drawing on reverse side. i t + Signed Title: _ '� Date: OR DEPARTMENT USE ONLY tar -.� Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: G ❑ Stk 466-6781 ❑ Lodi 369-3621-7 ❑ Manteca 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 INFO AMOUNT DUE AMOUNT REMITTED " CASH RECEIVED BY 1 DATE PERMIT"NO. + EH13-24(REV.t i e 5) •�� "I'�/ _ `� EH 14-28 / i