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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. ,. Job Address l'toy/ Jr r 'J City�/ L" Lot Size PM g — APf) Owner's Name Address �jr/y / '" "J AZ2 Phone ✓ Contractof/f `'V ! Addres j LyP L� License No./ rR 16 Phone � 2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ®-� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ..FOUNDATION_ AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 1 ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation L Dia. of Well Casing :91111Wet, Domestic/Private JGravel:Pacl . ❑ Tracy Type of Casing `< Specifications fl Public "M Other )0 Delta Depth of Grout Seal Ty e of Grout _ I I Irrigation —Approx. Depth�syi II EEaasje// urface Seal Installed by Repair Work Done El" Type of Pu_mGi �UH.P. ) 4-- State Work Done -- Well Destruction ❑ Well Diameter Sealing Material (top'50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION t I (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: Water table depth 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 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl 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 laws, and rules and regulations of the San Joaquin Local Health District. 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." Theapplic nt mus al all quired inspections. Complete drawing on revers si e. Signed Title: �d� Date: ! z FORkPARTMENT USE ONLY y� 4 Application Accepted by Date 1 a'�� J� Area / Pit or Grout Inspection by Date L v vFinal Inspection by Data d Additional Comments: ~ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 IC3 Tracy 835-6385 17 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO 1 /� Q J , EH 13-24(REV.lin 5) �SnV v V �J A.V•/v.S. i"`��u�V� S� I FH 11->A