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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. � I` Job Address 0 Q (0 `I 7 e City Wil/ Lot Size � PM ,,Owner's-Name, &dOtla-0, alY11 1-*CII` Address Phone Contractor JA Address_ �{} lci C�i �.q 9 License No. $ Phone 3 7 S f TYPE OF WELL/PUMP: * NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i 1 Public Other ❑ Delta Depth of Grout Seal Type of Grout r t i I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by k Repair Work Done ❑ sType of Pump H.P:' State Work Done Well Destruction Ll ► 'WOODiameter Sealing Material [top 501) }Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTr-/ALLATION REPAIR/ADDITION € I DESTRUCTION I I INo septic system permitted if public sewer is / _ available within 200 feet.) T - Installation will-serve Residence °C ommercial r . Ofher Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: /4 Gb b G Water table depth t SEPTIC TANK V� Type/Mfg P G Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ r 1 I Method of Disposal Distance to nearest: Well�.c'1� Foundation. hq Property Line •_„�,_._ i LEACHING LINE VN6.,&_Length of lines Total-length/siie'-'"° _ FILTER,.BED ❑ Distance to nearest: Well' Foundation Property Line SEEPAGE PETS C l `Depthh; _Size ' tt� X. 1 .r �'tr�J-�_-_._..-,_��_ N mbar SUMPS V,Distance to nearest: Well} Foundations Property Line DISPOSAL PONDS -❑ I hereby certify that I have prepared.this adplication 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 Healtli District. Home owner or licensed agent's signature certifies the folliiwing: "I certify that in the performance of the work for which this permit is issued, I shall nota f'' employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatu e_ certifies the following;"I certifythat iri the performance bf the work for which this permit is issued,-I,shall employ persons subject to workman's compensa- tion laws of California." Y The applicant must call for all eq ed inspections. Ci$mplate drawing on reverse side. Signed X a- L X �.M�' Date:; , FOR DEP ENT USE ONLY , . ._, ONLY Application Accepted by � _ .Date Area Pit or Grout Inspection by _ Date Final Inspection by Dateq//_f7 Ar i Additional Comments: f k ' ❑ Stk 466-6781 ❑ Lodi t 369=3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE }t LL INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 1 ...... i H s1 / / -�