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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE.- STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 AddressDu /� City Lot Size PM Owner's Name hthE Q•+b" Address Phone q (- ) 3 21-7 Contractor �L.-T t Address CLR +b Li License No.141D.R.19 Phone �A 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 ❑ Industrial ❑ Open Bottom_ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing 4.Specifications f'l Public f] Other n Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK; NEW INSTALLATION II REPAIR/ADDITION i,) DESTRUCTION ( septic system permitted if public sewer is available within 200 feet.l Installation will serves Residence_ Commercial— Other _1 Number of living units: Number of-bedrooms -r-- -:r .. Y• Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ yG t 1 Method of Disposal I Distance to nearest: Well Foundation Property Line i F LEACHING LINE ❑ Nan& Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size 4 Number SUMPS 1 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. i Home owner or licensed agent's signature certifies the following: "Icertify 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 ce11awf 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- tioCalifornia." +;Tht caU o II re red iti n late drawing on r arse side. SiTitle: Rate:/ r� 4 ' FOR DEPARTMENT USE ONLY iApplication Accepted by Date —Z/ Area _ Pit or Grout Inspection III by Data Final Inspection by Date td-it ionaI Comments: -� astk466 6781 '❑ Lodi 369 ❑ Manteca 823 7104 ❑ Tracy 835-6385 licant Return all copies to. Environmental Health Permit/Services:1601-E.-Haze[ton-Ave:;=f.O. Boz-2009, Stk. -CA 95201--- FEE 5201 -�-,- INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVE[) BY DATE ;PEMITNO. F ♦ EH 13-24 1REV.1/ii 5; 1 EH 14.26 � � l��