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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES f'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 _-. City Lot Size PM h Owner's Name !_ Ot' _„�% rass 32(Z4 Phone Contractor ress icense No. E Phone v TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ R PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l"1 Public (7 Other 71 Delta. Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ! DESTRUCTION I ) 1No septic system permitted if public sewer is a available within 200 feet.) Installation will serve: Residence_jL Commercial_ Other r Number bf living units: _�L Number of be ooms Character of soil to a depth of 3 feet: Water table depth E, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well-16- 4 Foundaatio-r Property Line LEACHING LINE 0 No. & Length of lines1 �Q Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Al Size Number ~ /SUOPS L� Distance to nearest: Wellj faundwion� /r Property Line '6f5P05AL PONDS El 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 Joaquiri Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performanc@ 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." �. The applicant must call for all requ�e ns ctions. Complete wing ofixteverse side. r Signed X Title: Date: /7A, ? 7 V FOR DEPARTMENT USE ONLY �� Applicati Accepted by t- Date = Area ort Ins c idtt b J PB Y Date I Final Inspection by Date 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 INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. r +.EH 13.24 1REV.I/n 57 •�/y/ JJff J(q( 2 EH 14.28