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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 ! (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health DP trict for a permit to construct and/or install the work herein described. This application is i made in compliance with San Joaquin County Ordinance No. 9*vAr sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM r � Owner's Name Address � 4 PRone r Contractor- ddress - L-icense-No.- �^v-"PhoneY-Yl -7-2 9 TYPE - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA ENT ❑ DESTRUCTION ❑ L PUMP INSTALLATION ❑ 5Y M REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK S ER L1 DISPOSAL FLD. PROP..LINE t �.#�1FOUNDATION AG LTU WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PR08L A A CONSTRUCTION SPECIFICATIONS 3 Ll Industrial 10 Open Bottom ❑ anteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private--=_T Gravel Pack Tracy Type of Casing Specifications i'1 Public 14 Other ❑ Delta -- -Depth of Grout.5eafy P t 9 Type of Grout_--,, i I Irrigation -Approx. epth I I Eastern urface Seal Installed by Repair Work Done __ ype of P p H.P ❑ .' State Work Done Well Destruction Q Well Di eter Sealing Mate 'al (top 5P, ` # i�Depth Filler Material 1 lowt5D'1 5 �_ TYPE OF SEPTIC WORK: NFW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic'system permitted if public sewer is 7--available-Within 200 feet.) A-installation will serve: Residence_ Commercialther c rp { Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Aj """"" "`" t Water table depth l SEPTIC TANK ❑ Type/Mfg rapacity /20 No. Compartments L v PKG. TREATMENT PLT. ❑ - Method o Disp at ' $ + r 1! Distance to nearest: Well F undation Property Line e7 LEACHING LINE ❑ No. & Length of lines r" Total length/size d k ( FILTER BED ❑ Distance to nearest: Well _ undation% Y Property Line / 1 I -r SEEPAGE PITS I 1 Depth Size I Number � SUMPS ❑ Distance to nearest: Well/ Found ation 2 1 Property Line Q DISPOSAL PONDS ❑ s �O i1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, arid r rules and regulations of the San Joaquin Local Health Diltrict. # f' 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 taws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 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." i k �f The applicant m t call for allr )red in ctions. Complete drawing on reverse side. -=�- I' Jr Signed X ^ f Title: [J�-�i(I�'t�o� �' Date: - i R ' FOR DEPARTMENT USE ONLY Application Accepted by Date � � " � Area 2 ! I Pit or Grout Inspection by Data Final Inspection by DateL !Additional Comments: HCl 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT NO. I _ +.EH 13-24•IREV.1'/n51 -- -T- -0-- -- ) EH 14-26 r`