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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED i= (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. tV it HILL f �� ff�f�Tlt Job Address / f� _1rcc .. _ iCity ��"' Lot Size PM Owner's Name T - AddressZ,23 I?- -- — J - Phone I Contractor Address License No,4.)-323 Phone z-� TYPE OF WELL/PUMP:• NEW WELL.❑ WELL R PLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.;❑ SYSTEM REPAIR' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER-LINES_: ;DISPOSAL FLD. PROF!, LIiVE. -r, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a Dia. of Well Casing L�Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 1 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern " Surface Seal Installed by Repair Work Done" ❑ Type of Pump}. H.P. ell _ State Work Done Well Destruction, s ❑ Well Diameter, Sealing Material (top 50') 9 , ,. y" "bepth Filler Material (Below 501 lt7 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 1, Installation will serve: Residence_ Commercial- Other Number.of living units:' Number of bedrooms f I Character of soil`to depth of"3 feet:" -. - -�5" w— a �-t- "yyateFutable depth"'" SEPTIC TANK ❑ Type/Mfg € ' ,Capacity 4 1" +°� ' No. Compartments PKG. TREATMENT PLT. 1719 i fir` , F�{ Method of Disposal Distance to:nearest: Well ;Foundation Property Line I 1 LEACHING LINE ❑ No. & Length of lines Total-length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line I ,. SEEPAGE PITS ❑ Depth Size ti Number , SUMPS ❑ Distance to'nearest:�—Well^ -F"�`�Fdundation'"! *• ""'y 'Property Line k _ DISPOSAL PONDS ❑ •.* 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 Joaquin Local Health District. - ?I 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, f 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 OT"Ta%ons subject to workman's compensa- tion laws of California." "•`i' i� ar�,.:" The applican st II for II r aired inspections. Complete drawing on reverse side. Signed �'�� itle: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date i Are / Pit or Grout Inspection by Date Final Inspection by - Date A F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 `" ❑ Tracy 8354385 «+w i Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT''NO. } +EH13.241REV.1/a5) EH 14-28 f4z)