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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) 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 !I Local Health District. Job Address � ► Y� � 19 City Lot Size PM Owner's Name Address Phone Contractor ' E Address&- ...-,.,_ ?5O License No4�`��-- Phone 9-5 TYPE OF WELL/PUMP: NEW WELL ❑ ` WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V. Bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation ` A g _ pproxiD epth [ 1 Eastern ,Surface Seal Installed by _ Repair Work Done ❑ Type of Pump _ H.P.- State Work Done Well Destruction ❑ Well Diameter. Sealing Material atop 50'I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I1 INo.septic system permitted it public sewer is I available within 200 feet.) .,7 Installation will serve: Residence Commercial_ Other a.s - R -Number of living units: Number of bedrooms -, DQCharacter of soil to a depth of 3 feet: 1 '`� '- - F `'Water table depth SEPTIC TANK ❑ Type/Mfg —,Capacity—// °�No. Compartments PKG. TREATMENT PLT. ❑ I '�* Method of Disposal ti Distance to nearest: Well Foundation ; Property Line LEACHING LINE ❑ No. & Length of lines Total,length/size FILTER BED ❑ Distance t6 nearest: Well Foundation Property Line f': SEEPAGE PITS I I Depth Size _ Number ' SUMPS ❑ Distance to nearest: Well Foundatio`n`"'�^^�— I Property-L-ine DISPOSAL PONDS 0 s I hereby certify that.I have prepared this application and that the`work wili'be done,in accordance with San Joaquin county ordinances, state laws, and _rules-and regulations of the San Joaquin Local Health Di%trict. Home owner or licensed agent's signature certify that the following: "I certhat 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 I The applicant must caH for all required inspections. Complete drawing on r verse side. ? i Signed Title- Date: l _— FOR DEPARTMENT USE ONLY Application Accepted by �i , Date Area p Pit or Grout Inspection by Date_ Final Inspection by Date 3l 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DAVE PERMIT'NO. ' +.EH 13-24[REV.1/8.5) EH 14-29