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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZE T ON AVE., STOCKTON, CA .� ' Telephone 1209) 4 // PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l b {Complete in Triplicate) ��- �►'1'\. Application is hereby made to the SanJoaquin 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. �I Job Address y City Lot Size PM Owner's Name r II Address _, 1+]�t o _ Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: Il NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE FOUNDATION AGRICULTURE WELL R WI=LL - PITS/SUMPS 16 INTENDED USE TYPE OF WELL PROBLEM ARE TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ ❑ Gravel Pacl ❑ Tracy Type of Casing Specifications i`1 Public {_1 ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth l l Eastern Surface Seal Installed by _ Repair one ❑ Type of Pump H.P- State Work Done_ u ell Destruction ED Well Diameter Sealing Material (top 50') Depth 'I` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION [ I DESTRUCTION No septic system permitted if public sewer is i - 'i� available within 200 feet-) Installation will serve: Residence Commercial . Other Number of living units: Number of bedrooms L 1 Character of soil to a depth of 3 feet. Water table depth w ; SEPTIC TANK .0 Type/Mfg; Capacity No. Compartments PKG. TREATMENT PLT. ❑ n Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line ¢ f SEEPAGE PITS I 1 Depth, Size Number SUMPS ❑ Distance to nearest: Well Foundation Property tine DISPOSAL PONDS ❑ f 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, anq:51 rules and regulations of the San Joaquin Local Health District. r 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 no� employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature I certifies the following: i certif. that in the performance of the work for which this permit is issued, I shall employ" y pe p p y persons subject to workman's compensa- tion laws of California." The applicant must call forallrequired inspections. Complete drawing on reverse side. x Signed X f Title: (�u J i Date: 1 rZ n h FOR DEPARTMENT USE ONLY L Application Accepted by Date r z`Z't7 Area Pit or Grout Inspectio y 'rIj Date Final Inspection Date II'_ Additional Comments: L'�-�1 ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ Manteca 8217104 ❑ fracy 835- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box k—C 52 II FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO �Q, +.EH t3-24{REV.r/x51 ��•�"�� EH 14-26 ' IC