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APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED •r ,r'-+ .�e,� ;� � F3 fir. x' ,''.f� {Complete in Triplicate) .syG 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. • ,� s_ l },� �J .3L 40 Job Address /Q / City Lot Size PM . Owner's Name Address Phone Contractor's Name GZ� LyuLLicense No. � L 3�/`4Phone 1C7 �� 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 ❑ Open Bottom ❑ Manteca jgia.lof.Well Excavation 'bia.of Well Casing ❑ Domestic/Private C] Gravel Pack ❑ Tracy Type of Casing a Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by__ Repair Work Done ❑ Type of Pump H.P. i State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ` - t= Depth Filler Material (Below 501 � 0 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ {No septic system permitted if public sewer is .1 available ithin-200-fnt'1'-—" ' Installation will serve: Residence Commercial_y Other ry } Number of living units:-j— Number of bedro s -� Character of soil to a depth of 3 feet: I Water table depth_ "^ SEPTIC TANK ❑ Type/Mfg l Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �[ No. & Length of ne�/ `W � Tot1l length/size FILTER BED ❑ Distance to nearest: Wel Foundation Property Line SEEPAGE PITS ❑ Depth Zize Number_ SUMPS ❑ 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, 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 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 applican ust all all re i d ' spections. Complete drawing on r verse side. L7_t�jtqSigned Title: Date FOR DEPART M T U5E ONLY Application Accepted by. E/ Date Area Pit or Grout Inspection by Date Final Inspeatio y Date Additional Comments: Ak ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 -- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., A.O. Box 2909, Stk.,.CA 95201 FEE g INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. + EH13-24[REV.101831 � - r EH 14-25 / �• OC3 /��I �_��