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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1F 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 applicatipn is made H compliance with San Joaquin County Ordinance Na.549 for.sewage or No. 1862 for well/pump and the Rules and Regulations of"m San Joaquin Local Health District. ti Job Address t I j //(ft�i N r. City Lot Size 7 Q Ct C,194� PM Owner's Nam Address D �Phone a Contract Ad ' ? / 7 Address 1 V �• License Na.sJ� 0�021� PhoneJ�cg` /�s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,r DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Mantecai Dia. of Well Excavation pia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ❑_Publicx-- -�- • Specifications .,_ T❑..Other w ❑ pelta ,_Depth.of-Grout_Seal ❑ Irrigation - —Typee-of Grout --Approx. Depth ❑ Eastern �,� ,,.Suiface,Seal Installed by '� {4` —Repair-Work 0__Type of Pump_ H P ' .�! `K z r r -K `State Work, Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is Installation will serve: Residence °/ Commercial i Otheravailable within 200 feet.} f t-- F Number of living units: Number of b dro ms�! C r Character of sail to a depth of 3 feet: - . 1 �', SEPTIC TANK __/ Water table depth Sd 4 L+7 Type/Mfg t� Capacity LJ No. Compartments O� PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well/ ' Foundation LAO— property Line 0'F4,LEACHING LINE F No. & Length of lines go Total length/size ® X FILTER BED ❑ Distance to nearest: Well Oe --.s1� Foundati-d'n`_ I d ._ property Line SOC 'f' f SEEPAGE PITS Cl-Depth _ Size33 lumber_ r� SUMPS ❑ Distance to nearest: Well Ind'' � DISPOSAL PONDS _.❑ Foundation:_]�C :' Property Line 1®o_ a I hereby certify that I have prepared this application and thatfthe work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District i, r Home owner or licensed agent, s„signature certifies the folloinring: '1 certify that in the jaerformance 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�ttie 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 call for all requir d inspections Complete drawing on reverse side. Signed a+. .r.� - s.: .:,d•ar - ;eTitle: Date: �. FORDEP 1T—TMEIIIT USE ONLY Application Accepted by � �"�.� Date / -� �-- Area Pit or Grout Inspection b ate f d CV Final-Inspection by Date Additional Comments: )(Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6305 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE gMOUNT DUE AMOUNT REMITTEDCK INFO CASH ' RECEIVED BY DATE PERMIT N0. + EH M24(REV. - EH 14-28 t k