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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION AVE., STOCKTON, CA N1D Telephone (209) 466-6781 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - ,�,. M (Complete in Triplicate) L Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work a I' n pp natio is E 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. Job Address 213 IV'- • City�4A Lot Size V S/ P P Owner's Nam Addressy^ ��Ti+�- Phone Q 2/ iq Contractor ?A .r.,e}s',. ! / e1XI 4 License No. F3"' Phone ten i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS ` + i ` INTENDED USE + TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mantece Dia. of Well Excavation,-- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Packs ❑ Tracy Type of Casing `y Spec'if'ications ❑ Public l r❑ Other ❑'Delta Depth of Grout Seal Type of Grout ❑ Irrigation '--Approx. Depth ❑ Eastern Surface Seal Installed by,...- Repair Work Done El [[[ Type of Pump H.P. State Work Done i. Well Destruction ❑ {Nell Diameter Sealing-Mi&rlal (top 50') Depth _ Filler Material (Below 501 TYPE OF SEPTIC WORK: .,NEW INSTALLATION ❑ REPAIR/ADDIT�=DESTRUCTION0 (No septic system permitted if public sewer is f ay. able within 200 feet.) kY Installation will se : 1 Residence_ Commercial— Other `, Number of living units:: .( Number of bedrooms /ZP� 'll v Character of soil tora depth of 3 feet: Water table depth t SEPTIC TANK i❑ Type/Mfg i Capacity O` sK No. Compartments f PKG. TREATMENT PLT. ❑ ' %_ t Method of Disposal . Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑...Distance-to nearest;---Well Foundation Property Line SEEPAGE PITS ❑ DepthSize Number SUMPS I❑_Distance to.nearest:,.„,,....WellFoundation Property Line DISPOSAL PONDS .i❑ t 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. [ t 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,(s-hall employ persons subject to workman's compensa- tion laws of California." f { The applicant must call for'all require 'inspections. Complete drawing on reverse side. Signed X l Title: - �1 Date: l aL r � TMTMENT USE ONLY Application Accepted:by! Date � 7 Area_ _d Pit Grout out Inspectwli n Y by. Date final Inspection b p ate r G j Additional Comments: ❑ Stk 4664781 ❑ Lodi 369:3621/ ,1 ❑ Manteca 823-7104 -❑ Tracy. 835-,M Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201kCK „ j 4 1FEENIF i AMOUNT DUE AMOUNT REMITTED, CASH RECEIVED BY DATE PERMIT"NO. : .' Zn - + EM 13-24 I"REV.,1%a