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t i APPLICATION FOR PERMIT SAN JOAiam LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 ( �� `0 �-O�! City ��Td Lot Size / y2 PM Owner's Name Address e/,LJI Z)Y- Phone Contractor Address / T /!2*�icense No. hone' ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ { PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f!, DISTANCE TO NEAREST: SEPTIC TANK �_SEWE-R-LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout 115 1 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 . a Depth tr` Filler Material {Below ') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is B available within 200 feet.) Installation will serve: Residence Commercial-...Other - Number ther .-Number of living units: _.� Nur'hber 6f bedrooms__�; ._ Character of.soil to a depth of 3 feet: .Y ' Water table depthi ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 0 PKG. TREATMENT PLT. ❑ -� Method of Disposal Distance to neardst: Well Foundation r. Property Line LEACHING LINE 0 No. & Length of lines T Y r Tot length/size. FILTER BED . Distance to nearest: Well-ZEaL_ Foundations Property Line �T4 f SEEPAGE PITS ❑ Depth ___4_ """Size "` - - iGnber SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 1 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 x rules and regulations of the San Joaquin Local Health District, 1 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." i y The applicant must call for all re(Aired i spections. Complete drawing on reverse side. i ' Signed X-- �� Title: Date: y 0 FOR DEPARTMENT USE ONLY 1 i Application Accepted by VQ, _ Date ' Area Pit or Grout Inspection byDate Final Inspection by ate -,7(7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Ll Tracy 8355-6385 1 Applicant- Return.all copies to: Environmental Health Permit/Services. 1601 E.'Hazelton Ave., P.O. Box 2069, Silk., CA 95201 FEE INFO AMOUNT DUE -'AMOUNT REMITTED'"' CASH m� pECEfVED B'' DATE��x PERMIT NO�� ^ EH 14-2a -+EH 13-24-(REV.5 i R s)