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�j 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 No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. j Job Address S City Lot Size F Owner's Name "T t TY^�I) r Pt Address Phone Contractor w A l,--v k A LL Address SO W C L 6_&icense No, r 0�49 Phone / 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 FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ 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 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION TRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 1.0/Commercial_,other Number of living units: _V Number of blBrgooms--- Character of soil to a depth of 3 feet: Water table depth �^ SEPTIC TANK ❑. Type/Mfg C Capacity No. Compartments U t 4 PKG. TREATMENT PLT. ❑ / Method of Dis sad Distance to nearest: Well Foundation Property Line LEACHING LINE �F-�iVo. 8 Length of lines t� otal length/size FILTER BED ❑ Distance to nearest: Well _ FoundationIDU Property Line SEEPAGE PITS N--Vepth Size Number SUMPS Ll Distance to nearest: Wall Foundation Property Line `- DISPOSAL PONDS El = 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 SanJoaquin Local Health Di§trict. 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 ny person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies th ollowing: "I y 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 ifornia." T pplicant c II r all qui in do o pre awing on r �4e-•Signed X itle: e �o Dater FOR DEPARTMENT USE ONLY Application Accepted by )1 Date '-` o -/Area / p Pit or Grout Inspection by Date FinalInspection by 4+-J+ F ' `7 Date 4 Additional Comments: /- "�Ja f Z✓c+J:c✓I/_f.� 9 ePcY x!� `- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385- o f Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. ♦.EH13.24 IREV.1/9 5) �� \ EH 14-26 ��-�