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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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 Districts.I Job Address `T' ;q rte ` City Lot Size 1f r PM AOwner's Name L Address !�a /� &4A-kPhona KContractor. Address License No. Phone TYPE OF WELL/ LIMP: 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 CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--- I rout -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 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l i DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res deuce Commercial Other Number of living units: J Number of bedrooms �D , Character of soil to a depth of 3 feet: C} �`Water table depth SEPTIC TANK &I Type/Mfg � Capacity-0/0No. Compartments � PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines dotal length/size 770 FILTER BED ❑ Distance to nearest: Well //4W � Foundation /0 Property Line __- SEEPAGE PITS I II Depth Size �, Number SUMPS Q7- Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS Cl 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 Di%trict. 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 employanyperson 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 st call for all required inspections. Complete drawing on reverse side. g k Signed X 1!Title: �. A 1 L Date: OR DEPARTMENT USE ONLY 7- ar=0 Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Dat 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASHID 0 /r /� + EH 13-24(REV.1/n 5) lt% `� /f /� T3a3 EH 14-28 11