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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 sI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I' (Complete in Triplicate) - r 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �� (o ` �� A-rJ�p City l Lot Size 2 r J PM Owner's Name�E�r'e- 0 S{ Address �� d f Phone 24 Contractor r - Address Z �� 2 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRtJCTtON ❑' a ff PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Km Y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. L{NE� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL, PROBLEM AREA CQNSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing w 'SL Domestic/Private ❑ Gravel Pack I�Tracy Type of Casing a Specifications F M Public C1 Other C1 Delta Depth of Grout Seal Type of Grout i t I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. x State Work Done Well Destruction ❑ Well Diameter Sealing Material (top.50') Depth Filler Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATI REPAIR/ADDITION I.I DESTRUCTION I I (No,septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence x '-, Commercial_ Other j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK Type/Mfg Capacity \t;D0 _� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal to nearest: well Foundation U _s Propgrtl,Line [1� r • t LEACHING LINE ❑ No. & Length of lines ' x- TotJ length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation- Property Line . SEEPAGE PITS I ) Depth::_... �t'� Size Number I. � t r i SUMPS ❑ Distance to nearest: Welles Foundation Property Line Q DISPOSAL PONDS ❑ I hereby certify thatl 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. 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 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, I shall employ persons subject to workman's compensa-g r tion'laws of California." A The applicant ust call fnr.alI required inspections. Complete drawing on reverse side. 4 " Signed X Title: �' z Date: 1 FOR DEPARTMENT USE ONLY (37 Application Accepted by Date r Area Pit or Grout InspectioDateqq Fina Inspectio rby L J Dat Additional Comments: 1`U• 1rt `r' e ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 835-6385 L Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box-2009, Stk., CA 95201 7 FEE AMOUNT DUE AMOUNT REMITTEDSH RECEIVED BY DATE ` PERMIT'NO. INFO s '+'EH13-241REV.rin5)� - Q � 9H,14-26 !7 - r ,�.