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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR 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. 2 Job Address ;_f�� -� Cit&��41 Lot Size PM 3 3 �cd—, 70 _ 363 Owner's Name Address G��Q' Phone .t° _A Conttact f1 res5 License No. --hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. w�PR�7P�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 pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications M Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth il[er Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR ADDITION DESTRUCTION { I (No septic system permitted if public sewer is f ` available within 200 feet.) Installation will serve: Residence Commercial_ ther - 0 Number of living units: —L_ Number Character of soil to a depth of 3 feet: � Water table depth T Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ,- PKG. TREATMENT PLT.-❑ Method of Disposal - '~ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines _ Tot at length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line - E SEEPAGE PITS Depth Size Number SUMPS L] Distance to nearest: Well Jon" _ Foundation In r Property Line_ DISPOSAL PONDS O 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: "1 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 of 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 applicant m s all for all r q 'red �spections. Complete drawing on reverse sid� Signed Title: ✓ _ Date:01v IJ FOR DEPA MENT USE ONLY ja,or lication Accepted by Date f Area Grout Inspection by at Final Inspection b� Dat Additional Comments.- 171 omments:❑ 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. *,EH 13.241REV.i5 __ EH 1426 L �— ti