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M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �~ (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Health District for a permit to construct andlor 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 - City Lot Size PM Owner's Name Address � � - Phone �97\13 Contractorffz Zjn6 dressnse N Phon TYPE OF WELOPU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI NCT PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (A 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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia" of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public -,,Fl Other F1Delta Depth of Grout Seal Type of Grout---. L}1� I I Irrigation r Approx. Depth l I Eastern Surface Seal Installed by l Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') 7 Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION I.I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_lE__ Commercial_ Other Number of living units: __ _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK fl Type/Mfg r _ - Capacity No. Compartments PKG. TREATMENT PLT. ❑ �9j �,� Method of Disposal Distance to nearest: Well OO tlndation (Property Line 4 D e" LEACHING LINE ❑ No. & Length of lines — Total.tength/size b FILTER BED ❑ Distance to nearest: "Well _sem_ Foundation 0= j Property Line SEEPAGE PITS I I Depth _ Number SUMP Ll 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: "4 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 applicant must call for all requir . in pections. Coritpl a drawing on reverse side. /f Signed X Title: 'L21 Date: FOR DEPARTMENT USE ONLY Application Accepted byDate ` Area Z Pit or Grout Inspection by Date Final Inspection by Datey� 1 f Additional Comments: ElStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all co ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. r"4i- INFO ^CASH r + EH 13-24(REV. 5) ��(„� �e ` � ! �,t�f 3 �,�, '( 9�1�3SC• EH 14.28 ll 1 �`r' �]