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APPLICATION FOR PERMIT = SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED 1 % i (Complete in Triplicate) Application is hereby made to theSan 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. it Job Address __� �� C�CP-1 Ee__ City Lot Size PM ' LL ll iip �v� f Owner's Name /71�� I: Address 32 14LYRJeJ41 c_ Phone 601 Contractor " r Address r ciC License No_U0Z 4 Phon(�e 6126 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ($ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �) D Industrial ❑ Open Bottom ❑ Manteca pia, of Well Excavatio �L. 1! Dia. of Well Casing rVI` Domestic/Private ❑ Gravel Pack E) Tracy Type of Casing— Specifications 71 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout _ i I Irrigation _..A,pprox. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth'1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW!INSTALLATION I] REPAIR/ADDITION I ! DESTRUCTION I ] (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_, Commercial_ Other Number of living units: Number of bedrooms -N Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg" Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No1& Length of lines Total length/size :s f FILTER BED. ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I 1 Depth Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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 k 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- tion laws of California." The applica ust c 11 f t all requir inspec ns. Cam lets drawing on reverse s/iddee.,r/� ,�y� Signed Title:��(��I�ey,Z4—.S P&9 ate: A Be ] FOR PARTMENT USE ONLY Application Accepted by Date Area OS ff .r}� „� -�y Pit or Grout Inspection by Date 1`. J'� Final Inspection by -' D2ia— 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. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 FEE INFO AMOUNT DUE CUNT REMITTED K RECEIVED BY DATE PERMI7'NO. 0 J + EH 13-24 1REV.1 51 Vf 6J �/ ,• EH 14-29 VVV CC��JJ// (rJ