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5 f Y ` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON "AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED L (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 Address , City Lot Size .LQply Owner's Name ' l/r!� 1� Address Phone Contract Qfjta'[4 Address J OCd`�� License No�o!1ZL(R Phone os— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE -- �-� -FJDUNDATION– -----^AGRICULTURE-WELL: -` OTHER WELL!' -- PITS/SUMPSY_ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing � ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public _ ❑ Other _❑ Delta Depth of Grout Seal Type of Grout _ iI I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Dobe ❑ Type of Pump H.P. r State Work Done _ Well Destruction 0 Well Diameter Sealing Material Itop`501 Depth r Material (Below 501 _ TYPE OF SEPTIC WORK: NEIN-INSTALLATION'(.1REpAIR/ DDITION' 6ESTRUCTION INo septic systeril permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial�'� Other--�_ # � �+ �–�-•--F-`– �- –- Number of living units: Number b droom Character of soil to a depth of 3 feel: 1 f p Water tabl depth SEPTIC TANK Y_ TypelMfg Capacity No.,Compartments PKG. TREATMENT PLT. ❑ i / ^" ' Method-of-Deposal Distance to nearest: Well ` Foundation,' Property Linei LEACHING LINE No. & Length of lines " length' /size iota! length/size- � r FILTER BED ❑ Distance to nearest: Well 7 b_ Foundation� Property Line' mac] SEEPAGE PITS Depth S Size r Number _ SUMPS D Distance to nearest: WeII" U_t2_ Foundation 1 0' ---Property Line-5L. �r DISPOSAL PONDS ❑ _ �-- rI hereby certify that I have prepared this application and that-the work Will be done in accordance with"San Joaquin county ordinances, state Maws, and L rules and regulations of the San Joaquin Local Health Di%trict. Home owner or licensed agent's signature certifies the following: "I.-certify that in the perforiha'nce 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,1 shall employ persons subjto workman's compensa- tion j. i tion laws of Calif ia." ect The applicant mu It forI qui d inspections. Complete drawing on reverse si + 7T Signed X Title: Date: PN L V FOR DEPARTMENT'USE ONLY Application Accepted byDate,,6' ,V, Area Pit or Grout Inspection by Date Final Inspection by f , '"Date Additional Comments: ❑ Silk466-6781 C] Lodi 36,9-36fl CI Manteca 823-7104 El Tracy.835.6385 4 ., f i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA i FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PER INFO CASH MIT'NO. +"EH 13-24 4RM 1/K sl EH 14-26 O•C'�- (�"y L f^�Q � �fi_' �