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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 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 o 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �� ace-4.r ,c7/f Job Address// _ 1L)r ?mg- ut. A ii City Lot Size PM r Owner's NamemAddress � 3� Z'z Phone ContractIYUy a4.,/l 11) Address/-.-, 80-K76 7 Y�{f License No.-3 �4 2 z(e Phone C� 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 Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. fill I I Irrigation __Approx. Depth t I Eastern Surface Seal Installed by _ �\ Repair Work Done ❑ Type of Pump H.P. State Work Done_ \ Well Destruction ❑ Well Diameter Sealing Material (top 50') \ Depth F'ller Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAI /ADDIT ON l DESTRUCTION I I (No septic system permitted if public sewer is ava ablw„ith- 2200�feet.) Installation will serve: Residence_ Commercial X Other Number of living units: Number of Yedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f� 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 .SEEPAGE PITS X Depth Size _,Number 11 - SUMPS ❑ Distance to nearest: Well Foundation Je-' 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 Diatrict. 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."Contractors 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 applic must call f all r wired inspections. Complete drawing on reverse side. �) Signed X Title: t,' Date: fYj v FOR DEPARTMENT USE ONLY Application Accepted by _� Date `'� 2' �� Area I Pit or Grout Inspection by / w`D/ate Final Inspection by Date Additional Comments: S�crlric� 3d.� --��,�—CL.40�Rr�a -t ti ❑ Stk 466-6781 ❑ Lodi 389 3621 v ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 0 INFO AMDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. a-EH 13-24(REV.i/m5) EH 14-26