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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T 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 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. �� G Job Address "' -+ C G City -�C_X Lot Size PM Owner's Name r� L I V 1 0`'9 Address 0154 Phone Contractor L. P70f l Address &)98V 1 � License No. d Phone____ S! 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 ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i"i Public Ll Other fl Delta Depth of Grout Seal Type of Grout I 1 Irrigation ,__Approx. Depth I I Eastern Surface Seal Installed by Repalr Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION [ I DESTRUCTION l I (No septic system permitted if public sewer is r '' ' / available within 200 feet.) ; Installation will serve: Residence V Commercial _mother Number of living units: A— Number of bedrooms_S7 Character of soil to a depth of 3 feet: ftbo6e. Water table depth SEPTIC TANK ) G Capacity No. Compartments PKG. TREATMENT PLT. p � y - Method of Disposal Distance to nearest: Well..-_(��r•�� Foundation— „`+ Property Line LEACHING LINE k'No. & Length of lines Total iengthIsize 7 FILTER BED ❑ Distance to nearest: Well AAC5141 Foundation __31 f_ Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll 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, a 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 applicant must ca for all r uir d inspections. Complete drawing on reverse side. Signed X Title: Date: " FOR DEPARTMENT USE ONLY Application A "�' / �Z.4 A pp ccepted by Date Area Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permii/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE CK 9 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24 IREV.r/n 51 EH 14-26 C".) '� Y