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APPLICATION FOR PERMIT ,y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA , 4 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. TNs 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 City Lot Size f � T PM Owner's Name G" Address L [ � 1�. j 5 Phone Contractor's Name re_. d Sic 14At License No. A9_.S Phone A�[s 7' C TYPE OF WELL/PUMP: 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 i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack E ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other_ "� 2 pelta Depth of Grout Seal a Type of Grout ❑ Irrigation _�__Approx. Depth ..,.❑ Eastern Surface Seal Installed-by, i Repair W6 Done---❑— Ty0e-5f-Pump, `" �_ _ H.P. i `St ie Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') i I Depth �'ti Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ` available within 200 feet.) installation will serve: Residence_ Commercial'-—Other --- t -� Number of living units:_ Number of bedrooms A. 1 Character of soil tol a depth of 3 feet: ( Water table depth SEPTIC TANK Type/Mfg r opacity Zd?� No. Compartments ' PKG. TREATMENT PLT. ❑ V� Method of Disposal :Ar Distance to nearest: Well/ Foundation 16 Property Line LEACHING LINE PL No. & Length of lines - Total length/size A FILTER HED ❑ Distance to nearest, Well� Foundation `.0", Property Line SEEPAGE PITS ❑ Depth Size'__ Number SUMPS ❑ Distance to nearest: ,Well Foundation Property Line DISPOSAL PONDS Cl 4 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: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to becomesubject 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, I shall employ persons subject to workman's compensa- tion laws of California." d ' r - The applicant mus j or all r1quired-insp9etions. Complete drawing on reverse side. Al Signed Title; Date: F R DEPARTMENT USE ONLY M 'App'lication Accepted by . 2Z�11Date rea Pit or Grout Inspection by Date Final Inspection by Date 1 yh/ .I I Additional Comments: k ❑ 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 L FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24(REV.10193) is s ?`g 711,��Lfi EH 14-26 1