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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i 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 District for a permit o. construct and/or the work herein described.This application is and nd made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well!pump athe Rules and Regulations of the San Joaquin Local Health District. I {� City Lot Size PM Job Address [ �� 9 J/CJ_57] t ']LJ "D� Phone 0 �y �' a Address t Owner's Name t _ 7 70 Contractor - Address License No.�-�Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ OTHER El .1 INSTALLATION 17 SEWER REPAIR-❑- SEWER LINES _ DISPOSAL FLD. PROP. LINE l DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ll Industrial Type of Casing Specifications El Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout ❑ Other Cl Delta ' I'1 Public i I Irrigation Approx, Depth 1 I Eastern Surface Seal Installed by t H Repair Work Done ❑ Type of Pump P State Work Done Sealing Material (top 501 Well Destruction ❑ Well Diameter Filier Material (Below 50') Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTIO I (No septiclable system thin m rmitied if public sewer is Installation wilt serve: Residence— Commercial_ Other I Number of living units: Number of bedrooms . Water table depth Character of soil to a depth of 3 feet: No. Compartments ` SEPTIC TANK ❑ Type/Mfg D(a P Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: iProperty Line PermtDaveEXp1r& U} �Gt�9th/size LEACHING LINE ❑ Distance & Length a lst Property Line FILTER BED ❑ Distance to nearest: by � ^i 'Hj hZ}�Qn ] SEEPAGE PITS l 1 Depth Size NumberPro a Li SUMPS Ll Distance to nearest: Well Foundation Property i 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 Di§trict. e following: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies th i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's lsubject to oorkman'sgcompensa- 1 certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons tion laws of California." The applicant mu t call for all required inspections. Complete drawing on reverse side. q a Title: Oi.-orl p_f Date: Signe X +&j4 FOR DEPARTMENT USE ONLY j Date r � � � Area ! Application Accepted by Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: L] Stk 466-6781 ., CILodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 fApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED By BATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH j INFO `�`� � /® Q � / + EH 13-24(REV.5/n 5) r EH 14-2e