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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 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. Job Address ! 1 U -7 ? F ro 1 (-G�f J City "[ "` �/Lot Size PM Owner's Name U }�'r eS Address 10 ( i' i 4 Phone / Contractor Address License No. Phone 93l-,5'7Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK f 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 Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t F] Public 171 Other 71 Delta Depth of Grout Seal Type of Grout__, (� I I Irrigation Approx.,Depth--^I I-Eastern Surface Seal Installed by _ ^� Repair Work Done ❑ Type of Pump H.P. State Work Done aQl E Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 Depth Filler Materia Below 501 a TYPE OF SEPTIC WORK: NEW INSTALLATION l.'1 REPAIR/ADDITIONA, DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resiyfence Commercial- Other Number of living units: - Number of be rooms f Character of soil to a depth of 3 feet: Water table depth I� SEPTIC TANK Type/Mfg Capacity . No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line h SEEPAGE PITS I I Depth Size_.r11 — Number SUMPS Cl Distance to nearest: Well [ �C oundation Property Line DISPOSAL PONDS L] j r 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." f The applicant m call far all required inspections. Complete drawing on rev rse side. Signed X �,� J Title: Date: 4 FOR DEPARTMENT USE ONLY 1 Application Accepted by Date Area 1 Pit or Grout Inspection by Data Final Inspection by I Date Additional Comments: 42 l/fll��(/Y�7`(� d'oa 2. . 1/4/3 SOux, l 14M1741 104 5s4 ID Stk 466.6781 ❑ Lodi 369-3621 El Manteca 823-7104 E) Tracy 65-638�AS L)V1 GOvP��4,; jvl Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201&Uu_4M16 WAS FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE /, PERMIT NO. Ne..EH 13-21(REV.t i H 51 "`�]® '' /� ^(�U Izzwl ��._x'2'"7 �r�-z2,3'ZEH 14-M / r! [/ l tt