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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/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address q iI I City Lot Size PM 1 Owner's Name Zdress , - - Phone 7� � - Contractor's Name (cense No. Phone r r (� TYPE OF WELL/PUMP: NEW WELL E WELL REPLACEMENT ❑ DESTRUCTION ❑ �• PUMP INSTALLATION ❑N SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK L f SEWER LINES DISPOSAL FLD. PROP. LINE 4 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 N ❑ Domestic/Private 13 Gravel Pack ;❑.Tracy Type.of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal i� Type of Grout C1 Irrigation --Approx. Depth © Eastern Surface Seal Installed by` R Repair Work Done ❑ Type of Pump H.P. -y ffState Work Done rr=�+-� � F;1'40 Well Destruction ❑ Well Diameter Sealing�Mat&ial (top '1 Depth Filler Material(Below-50') TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r} available within 200 feet.) I Installation will serve: Rest encet Commercial Other I Number of living units:7 Number of bedroom. Character of soil to a depth of 3 feet:{I F Water table depth n� ' SEPTIC TANK € Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of D' 5paI Distance.to.nearest:.. wellFoundation Property Line I. - �. LEACHING LINE r No. & Leng h of lineTotal length/size FILTER BED ❑ Distance tol nearest: Well ' Foundation Property Line Ql SEEPAGE PITS 11Depth size Number �2_ SUMPS r Distance toynearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be doneg:in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t t Home owner or licensed agent's signature,certifie's 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 Cal'iforni I e The apple u c I f re ire i s. Co let awing o se sitle. r Signed FF Title: Date: F It FOR DEPARTMENT USE ONLY Application Accepted by Date Area Final Inspection by Date Pit or Grout Inspection by Date . ,..�� Additional Comments: i ❑ 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,. INFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE 1gV_q3'2]_ PERMIT"N0. FEE+ EH 13-24(REV.101931 ! 5_011 /v ,��i'LEH f4-29TTT rJ T