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APPLICATION FOR PERMIT i' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 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 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. q `/ ,/ Job Address ® '•r f� City '47 ` Lot Size Aw r X00 _ PM Owner's Name t>a 3A CG I Address Phone t License .No. Phone Contractor L Address vl ' 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 I — ___j�0 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private - ❑ Gravel Pack ❑ Tracy- Type of Casing Specifications ' i f'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout 1 Irrigation �..Approx. Depth: !1 Eastern` ' Surface Sep Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction i ❑ Well Diameter Sealing Material (top 501 '; Depth Filler Material (Below 501 TYPE OF SEPTIC.WORK: NEW INSTALLATION 11 REPAIRIADDITION l I DESTRUCTION (No'septic system permitted if public sewer is '• available within 200 feet.) s Installation will serve: Residence's Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of,3 feet: D V -d7�A'� —Water table depth SEPTIC TANK ❑ TypeANIN Capacity No. Compartments ' IMethod of Disposal PKG. TREATMENT PLT. ❑ y '` a,. I Distance to nearest: -"Well""``"' " -Fouridation Property Line LEACHING LINE1 ❑ No. & Length of lines' Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line a SEEPAGE PITS # i I Depth Size Number a SUMPS I ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ '• _ - j " 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. '! 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, l shall not k employ any person in such manner as to become subject to workman's compensation jaws of California.` Contractors hiring or sub contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa tion laws of Califomia." f The applicant must call for al equjW inspections. complete drawing on reverse side. y Signed X Title: �""`�� Date: i FOR DEPARTMENT USE ONLY LP4 A lication Accepted d b Date Area PP p y 3 r � Pit or Grout Inspection yr—l Date Final Inspection by Date r Additional Comments: r �� ElStk 466-67811. Lodi 369-3621 ❑ Manteca -7 04 C] Tr,acy 835-6385 = Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T y FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY—� DATE PERMIT NO., INFO -- - ( � .ha + EH 13-24 TREY,t n51 $r^cZ'Q ` �-�Q 0 i3 • Lite >J • �S� �� i EH 14-26 J