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i� . I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON AVE., STOCKTON, CA Telephone (209)'466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i ' (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. I 7 I Job Address 7 �J City '�� Lot Size � PM Owner's Name "4 ��. Address 3� �� 0 �� 9r` "' Phone Contractor's Name ®w ! License No. �� Phone6Z6/ i TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. RO LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS kiJi ❑ Industrial ❑ Oen Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casings L 4 I - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications VV ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of G_104_, T s ❑ Irrigation IApprox. Depth ❑ Eastern Surface Seal Installed.by �� i Q Repair Work Done ❑ Type of Pump H,P. ' iStat Work'Don "- r --j- Well Destruction ❑ WellDiameterSealing Material [top 50'1 1 ) Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if,publid sewer is �I available within 200'feet: Installation will serve: Residence_ Commercial Other ` 1 a Number of living units: IM Number o tZedrooms Character of soil to a depth of 3 feet: [ Water table depth SEPTIC TANK �fype/Mfg a d' C '�'� Capacity i/ 'lam �sNlo`Compartments PKG. TREATMENT PLT. ❑ �. /� Method of Disposal ' = � Distance to nearest: Well fo Foundation �� ' Property Line �' 1 a LEACHING LINE No. & Length of lines Z ./CJ��f Total length/size 'ZOO F'jly FILTER BED ❑ Distance to nearest: � Nleli BOO f Foundation 57 I Property Line /a� _ --. SEEPAGE PITS Ifs' DepthZ�� Size /iYFH. _ Number Z ��rr r SUMPS �'r / ❑.Distance to nearest: Well 300 Foundation 1 11 Property Line 3 3 DISPOSAL PONDS 1 I� ; 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.. Home owner or licensed agent's signature certifies the following: ".1-certify_that in the.performan�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 fy 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." The applicant must- s �p rre spe Complete drawing on reverse side. GG 7 Signed 11 Title: Dater OR DEPARTMENT USE ONLY i i -�] Ap6licat,nl Accepted by. 3� ` °�^^^^ du Ae Date ' Area b j,opQk 1 C�lI Mt•cs"� `�l>L Date A-0,-6, �� .a� Data Y- Pit or Grout Inspect jion by a . >_ Final Inspection by,— - Additional Comments: ❑ St 13 466-6781 v 13Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-M S Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' I FEE AMOUNT DUE AMOUNT REMITTED� ASH x V,t,RECEIVED BY DATE fERMIT'NO.'INFO EH 1324(REV. 101831 EH 14-26