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4ic 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 k. , (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. jt: ' . . . . +, Job Address City /V Lot Size -PM Owner's Name J ' T Address - Phone I Contractor Address s o�/oZ0 kOl 4: � k,"License No. '3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP,LAC MEN,r p DES7RUCTlON ❑ PUMP 1NSTAL�LAAT ON J ��L� EP\ ►C7-PJ.fK677JitITG' REPAIR Q OTHER ❑ DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO EM AREA �GONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom nt �� "ideI�n�a ` �a of1lell.Excavat r Dia. of Well Casing ,rk)Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing� r Specifications ❑ Public ❑ Other 1 ❑ Delta`AW)d I 1 Depth of Grout-yeah` _- ❑ Irrigation - . Type of Grout g ---Approx. Depth ❑ East . T"— ~' a� �urfe Sealylnstalled"hy Repair Work Done ❑ Type of Pump H.P. _L< State Work Done 7►qv Well Destruction ( El Well Diameter - $eating Material {top 5p4) P�y� kJz � 1 Depth Filler Material (Below 50'1 / TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DES,TRUCTION ❑ (No septic system permitted if public sewer is ii available within 200 feet.) Installation will serve: Residence, Commercial— Other Number of living units: Number of bedrooms t� Character of soil Capacity—to a depth of 3 feet: Water table depth N SEPTIC TANK EJType/Mfg Ca P Y No. Compartments • PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑' No. &Length of lines h Total length/size FILTER BED EJDistance to nearest: Well Foundation Property Line SEEPAGE,PITS ❑' Depth Size Numbers SUMPSC _ „. ❑ Distance to nearest: Wel Foundation Property Line Inot DISPOSAL PONDShereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,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 employ any person in such manner as to become subject 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." The applicant m I,f all re inspections. Complete drawing on revecKoside. f Signed �".• 'r' ! Title: FOR DEPARTMENT USE ONLY Application Accepted by Date ` ` Ar, Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Ha2elton Ave., P.O. Box 2009, Stk 1 FEE AMOUNT DUE AMOUNT REMITTED T INFO CASH RECEIVED BY DATE nIT-+ EH 13-24{REV.7�H5)EH 14-26 I