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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 ..A t.K� G` ,7 e , I_0.Ajc, 1-7 )f'E,E, t wLp City Lot Size / PM Owner's Name G r Address a - Phone ILS S 3 fi p Contractor rt S License No. - .phone_/ (a TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ 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 1` Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence t�Commercial_ Other Number of living units: J_ Number of bedrooms - :5 _ Character of soil to a depth of 3 feet: -S © Water table depth SEPTIC TANK i$---fype/Mfg CapacityLAIDD No. Compartments PKG. TREATMENT PLT. ❑ ` Method of Disposal a Distance to nearest: t Wellt�? Fo !undation 1_D_ Property Line LEACHING LINEo. & Length en gth of lines �.��. Total length/size— Lk �� FILTER BED ❑ Distance to nearest: Well" L® Foundation�XD0 Property Line s� SEEPAGE PITS ❑ Depth Size U Number f SUMPS XDistance to nearest: Well„Foundation " Property Line DISPOSAL PONDS ❑ 1` , . j 1 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. ,' -Y-9 Home owner or licensed agen-t's signature certifies the following: `'I certify that in the performance of the work for which this permit is issued, I shall not e y any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature cefi he following:"'I ertify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iaws California." {- e The applican st all for req 'ed in cti n .TM p drawing on reverse si ! Signe Title: Date: FO ARTMENT USE ONLY � r ' Application Accepted y Date Area 0� 4 � / Pit or Grout Inspect y Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNtIRIEMITTED INFO --yCASH RECEIVED BY DATE PERMITN0. + EHi3-24{REV,t/951 /� ^� ,-2 �w[In �,� EH 14-ZB YJ Ywi/ 0"6-/-5W / �1