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I rt APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 City -s Lot Size PM Owner's Name,.&Ze �/ ��V• Address ,A?At,2! T O P h Jq&Z QAPhone Contractor Lis Address go&r< !Xf 4Yoe&*7&te1 License Nok_ 5�2`f'//`]Phone � y- E 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 INTENDED USE TYPE OF WELL PROBLEM AREA _6NSTRUCTION SPECIFICATIONS' } ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia.-of-Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing `Specifications 1-1 Public 17 Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation -Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 J- Depth Filler Material 16elow 501-', — TYPE OF SEPTIC WORK: NEW INSTALLATION f] REPAIR/ADDITION DESTRUCTION ( 11No septic system permitted if public-sewer is �I k I available within 200 feet.) + Installation,will seine:. Residence >!L� Commercial_ Other Number of living units: Number of bedrooms 2— Character of soil to a depth of 3 feet:1 Water table depth SEPTIC TANK Jy Type/Mfgl Capacity L U No. Compartments `. PKG. TREATMENT PLT. ❑ 1 Method of Disposal. f Distance to nearest: Well Foundation Property Line /t' oe 1 L LEACHING LINE ❑ No. & Lerigth of lines Total length/size FILTER BED ❑ Distance,to nearest: Well ---Foundation -Property Line +I SEEPAGE PITS i I Depth ! Size Number r SUMPS Ll Distance fo 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 Diltrict. 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 tojbecome 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." [ The applicant ust call for all required inspections. Complete drawing on reverse side, ^� Signed X Title: CA26 Data: s � r R DEPARTMENT USE ONLY p Application Accepted by OQLL �l Date � AArrea c� i, Pit or Grout Inspection by Date Final Inspection bDate Additional Comments: } ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE OUNT REMITTED WA"SFI RECEIVER BY DATE PERMIT ND. INFO {` +.EH 13-29 IREV.3!H 57 ` � -Zr TO— EH 14.26