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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone f209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) x 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 Healt istrict. '0.5Q O t7 S. C��e ru�CeQ. + Job Address City LOA t _ Lot Size PM Owner's Name L0. 0 '0 - Address f ZZI t. !f'lrtrN 7f tC 14c[TTq TAA Phone Contractor ,9- Address S_ H,>/, Ml A')?ZS License No. Phone /$ Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHE�RIINELL PITS/SUMPS' INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION'SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavat, — Dia. of Well Casing 2—I Y1G4. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy_ Type of Casing f Ir Specifications Jita 7� y��Other•-• ❑ Delta Depth of:Grou't Seal _ " Type of Grout ❑ Irrigation WAS �K�' pprox. Depth ❑ Eastern Surface Seal installed by Ip ' Repair Work Done ❑: Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 5: IM. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 'DESTRUCTION ❑ {No septi system permitted if public sewer is i available vithiri 200 feet.) I Installation will serve:; Residence— Commercial T Other { i Number of living unit§ 1-.Number'of'bedroartts Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments,: �M ' PKG. TREATMENT PLT. ❑ - - - Method of Disposal ISI l Distance to nearest: Well Foundation Property Line - I LEACHING LINE ❑ No. & Length,of Dries Total length/size r FILTER BED ❑ Distance to nearest Well Foundation Property Line' - i SEEPAGE PITS ❑ Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I r 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 lJoaquin Local Health District. Home owner or licensed agerit's signature certifies the following: "I certify that in the performance of the work for which this permit i)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 tri 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 call for all required inspe ons. C to drawing on reverse Signed X ' Title:_ side. Date: z I o J ' R EP T USE ONLY Application Accepted bArIpa �} Pit or Grout Ins cti y _ Date e}— � Final Inspection by Date 1=�� Additional ommen i-J Stk 466-6781 L} Lodi 369-3621 ❑ Manteca 1123-7104__ 1.7 Tracy W835-6385 Applicant - Return all copies to: -Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY CASH DATE PEV�R'MJIT)N.�O . EH 11324(REV EH 4 2 . 7 .4 ."2ys";