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APPLICATION FOR PERMIT 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/purrip and the Rules and Regulations of the San Joaquin Local Health District. r 7 Job Address -� �� >'`� ✓�h (/fr1�� Y City per' j` Lot Size �C�� , r PM Owner's Name Address Phone // p t Contractor's Name A Erb license No. f Y •7 Phone Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ "" -- - —----PUMP INSTALLATION!-Cl SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK L 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C7 Public ❑ Other ;.❑ Delta Depth of Grout Seal Type of Grout r� (71 Irrigation --Approx. Depth .-❑ Eastern Surface Seal Installed by Repair Work Done ❑ Typa of-Pump H.P. State Work Done \� Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF.SEPTIC WORK: NEW INSTALLATION.O REPAIR/ADDITION ❑ DESTRUCTION ❑ INo 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: Water table depth .s SEPTIC TANK a Type/Mfg V_4%� CapaciC,_ No.i;Compartmemd PKG. TREATMENT PLT. ❑ Method of Dispos pi I f Distance to nearest: Well Foundation Property Line —� LEACHING LIME fd No. & Len Length of line — ` y 9 �' _ Total length/size C FILTER BED El Distance to nearest; Well oundation �C / Property Line � 6� TV -- SEEPAGE PITS 23- Depth <3 7fi -� S' Size 7 -9 X ? ` Number .21 I SUMPS ❑ Distance to'nearest: . Well Foundation Property Line LiLr DISPOSAL PONDS ❑ i S = 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 sign re certifies the following: "I.certify that in the performance of the work for which this permit is issued, I shall not G employ any person in such manner a become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the fotlowting:"I certifythat' he 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 c fo I r inspecti s. o Tete dr wing on rre+v�erse side. Signed INtle: _!��1.,-�� Date: _ - OR PARTMENT USE ONLY �{ Application Accepted by Date ZS-� Area ©/ f®r rout Inspection by ate r Final Inspection by_�/ r Date Additional Comments: O Stk 466-6781 Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return aI 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 DATE PERMIT`NO.' �I J + EH 13-24(REV.10183} ,,,7 ('� EH 1426 �s O-1