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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 he ribed.This ication is made in compliance with San-Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a Regulations of the San Joaquin Local Health District. I Job Address t L^sJ / )Z O City u! of Size �pM Owner's Name v "B�/I D L Address Phone �7 77 Contractor Address License No. Phone .� TYPE OF WELL/PUMP: t 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavatiori Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta4-- -�Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of ump H.P. State Work Done # Well Destruction - ❑ Well'Diameter; .,. --�Sealin'g Material (top 501 -. Depth Filler Material {Below 501 4\ TYPE OF SEPTIC.WORK: NEW INSTALLATION 9-' REPAIR/ADDITION Cl DESTRUCTION C7 (No septic system permitted if public sewer is s available within 200 feet.) 'Installation will seFnie:�Residence>(- Commercial— Other Number of living-u tts: Number of bedrooms Cha atter of soil to a depth of 3 feet: " ' Water table depth v • SEPTIC TANK Type/Mfg Zr0 dCap city */2B c7 No. Compartments PKG. TREATMENT PLT. ❑ �y.A �� Metnad of Disposal ' r Distance to nearest: Well��Q Foundation Property Lin �_ �, '; ` 77 LEACHING LINENo. &Length of lines t TotaLlength/size •' ,_ FILTER BED `❑' Distance to nearest: Well1��;�Foundation� fD t= property one IJ SEEPAGE PITS Depth Size SUMPS ❑ Distance to nearest: Wey� Foundation roperty 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 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 e employ any pars i s cla man r as to becomd subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo wl certi th t in the pe rmance of-the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of alifor The applican st I r all fired r pections. Complete drang on reverse side. wif Signed Title: Date: _ FOR DEPAR ENT USE ONLY Application A e ed by TDate �� gree x -4 •ya_ lis +• T._ F-.y�. - - — Pit or Grout.lnspection,by , ate v Final Inspection by Date m Additional Comments: --- ❑ Stk 466-6781 XtLodi 36S-3621 D-Manteca 823-7104 ❑ Tracy $35 6385 ' Applicant- Return all opie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED 8Y DATE PERMIT'NO. +EH 1814(REV.1/$6) /17 EH 14-26 l 0(tom ��✓�J I