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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA t` Telephone (209) 466-67$1 (, PERMIT EXPIRES`11 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 Regulation's of the'Sari Joaquin Local Health District. Job Address—` ,yam Cc, City Lot Size � _ PM Owner's Name Address<�T s Z < T tg Phone�3 ��-o_• �,3 c�7 Contra cto � Zi; - Address Ab & �,0–uT License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ PUMP INSTALLATION O�, SYSTEM REPAIR G' OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD. PROP. LINE r G FOUNDATION AGRICULTURE WELL _-- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing KDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other * ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth O Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump H.P. State Work Done -� Well Destruction ❑ Well Diameter 'Sealingg Materia0top 50 Depth *Filler-Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR%ADDITION ❑ DESTRUCTION ] (No septic system permitted if public sewer is t i '� t available within 200 feet.? Installation will serve: Residence_ Commerciale..,-� Other_ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .__ t Water table depth SEPTIC TANK ❑ Type/Mf x`� Q 9 Capacity?`� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well t – -y Foundation Property Line LEACHING LINE ❑ No. & Length of lines ` 9 - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size ' Number SUMPS ❑ Distance to nearest: 4,Well —Foundation Property Line DISPOSAL PONDS Cl i 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 fog which-this permit is issued, I shall not employ any person in such manner as to become subject to workmen'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." r�. ` The applicant must call for all required inspections. Complete drawing on reverse side. Signed X _l Title: Data: ,AOR DEPARTMENT USE ONLY Application Accepted by Date / _ Area Pit or Grout Inspection by _ Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca- M-7104 G-Tracy 835-6385 Applicant - Return all 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 PERMITNO. ' S� EH 13-24(REV.1/a 5) - EH 1 -28