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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 103 �F4S 1601 E. HAZE 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. Jab Address 2MV-0_q�� City Lot Size __f- nPM �� / Owner's Name Address I -- Phono .—i. Contractor _ Address 7�� _ � L/ Icesnse No.-3S� a Phone 3Y /l36 TYPE OF WELL/P P: NEW ELL ❑ WELL REPLACEMENT ❑ OESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ .OTHER ❑' DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD.__ PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �' S industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing L1 t 'K DomesticIPrivate ❑ Gravel Pack L1 Tracy Type of Casing Specifications s -. a ('1 Public ❑ Other n Delta Depth of Grout Seai Type of Grout_..._..__ I I Irrigation r —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Cl Type of Pump H.P. State Wo Well Destruction Well Diameter Sealing Material (top 501 v Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is G available within 200 feet.) Installation will serve: Residence_-_ Commercial_ Other Number of living units: Number of bedrooms VVV Character of soil to a depth of 3 feet: Water table depth —_ SEPTIC TANK ❑ Type/Mfg _T Capacity No. Compartments k PKG. TREATMENT PLT.G Method of Disposal VE Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS G 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, 1 shall not empty 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." t._ The applicant m t all for all ro Inspections. Complete drawing on reverse side. w Signed X �jTitle: Date: _ V FOR DEPARTMENT USE ONLY Application Accepted by �_Ir �" _ Date l r Area Pit or Grout Inspection by Date Final Inspection by Date Z— f 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 k FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMrr N0. INFO CASH �.EH 13-241REV.1/M 51 EH 14-29