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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT � � -dam 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1`YEAR FROM DATE ISSUED i (Complete in Triplicate) f d 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 e Local Health District. ' Job Address v iz5-• City Lot Size X�xf�S pm Owner's Name Cniractar AXddddress Phone Addresst ' -7z�, "5 *: G License NoAx�6P hone QW _ 91g-7� , i TYPE OF WELL/PUMP: ;h 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 ° ❑=Industrial EJ Bottom ❑ Manteca Dia. of Well Excavation '� Dia.bf Well CiSing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type.of.Casing Specifications t x A { F 171 Public n Other n Delta Depth of Grout Seal Type of Grout I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - {I 4 Repair Work Done ❑ Type of Pump H.P. State Work Done i s Weil Destruction ❑ Well Diameter Material itop 501 Depth r Filler Material (Below 50'1 T Q TYPE OF SEPTIC WORK:} NEW INSTALLATION I 1 REPAIR/ADDIYION`i I .-'DESTRUCTION l I (No septic system permitted if public sewer is avaiWbe wit in 200 feet.) " Installation will serve: Residence Commercial other - s fJ,,Number of living units: Number of bedrooms f ✓ Character of soil to a depth of 3 feet: h F -• - Water table depth 4 _,,., r -SEPTIC TANK ❑ Type/Mfg c �= Capacity No. Compartments k PKG. TREATMENT PLT. © _ Method of Disposal Distance to nearest: Well Foundation Property Line `L+EACHING LINE ❑ No. & Length of lines Total length/size Is FILTER BED . D Distance to nearest: Well f I Foundation Property Line I SEEPAGE PITS i I Depth Size Number -SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I,hereby certify that I have prepared this-applicdttiori 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. I - 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 become subject to workman's compensation laws of California." Contractor's 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." f j The applicant-must-call for-all required inspections,Gomplete drawing-on-rovers - kfu-------" `"' j- I — � Signed X Title: Date:_. - FOR DEPARTMENT USE ONLY 1 t Application Accepted by Date ea Pit or Grout Inspection by Date Final Inspection by Date �I A dilional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. INFO �-y -P-7-27 7 + EH 13-241REV.I h5) �� 35 EH 14-2e -