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APPLICATION FOR PERMIT e SAN JOAQUIN LOCAL HEALTH DISTRICT l/�J 1601 E. HAZEL T ON AVE.;,STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES -YEAR FROM DATE ISSUED .1 "._, R• 4Complete in.,.Triplicatel:. Application is heieby 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. " �`� q r ,.` � :z Job Address .J 1 ! �. O sr ;a F �+ K L City �7 I\ r Lot Size_ b PM 3 _ el Owner's Name ddress _ +3 I" Phone Contractor ;-, � Address License No. e Phone- 1' 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EJ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE FOUNDATION AGRICULT LL OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL P AREA CONSTRUCTION SPECIFICATIONS L ❑ Industrial ❑ Open Botto ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ G ack ❑ Tracy Type of Casing Specifications ❑ Public Other ❑ Delta Depth of Grout Seal Type of Grout { j ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by { Repair o Done ❑ Type of Pump H.P. : • *,.State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') I i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION-' (No septic system permitted if public sewer is available within 200 feet.) Installation will serve'' Residence"_ Commercial— Other f f l Number of living units: A " Number of bedrooms ' Character of soil to a depth of 3 feet: M f Water table depth " SEPTIC TANK ❑ Type/Mfg r Capacity— - _ !? y No.'Compartments PKG. TREATMENT PLT. ❑ Method of Dispose! Distance to nearest: ; Well Foundation Property Line i LEACHING LINE ❑ No, 6 Length of lines �t.,, + __ Total length/size h }' FILTER BED –. r. T ❑ Distance to nearest: Well' Foundation ' propertjr Line t f• - , - }t SEEPAGE PITS ❑ Depth Size SUMPS ❑ Distance to nearest: Well Number T ^- - Foundation Property Line DISPOSAL PONDS ❑ i 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 .µ —rules 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." � ��: � _" Thea plicant must cal!for II required i ction . Complete drawing on reverse side. , a J Signed" .Title: Date: FOR DEPARTMENT USE ONLY Application Accepted b� l Date A a Pit or Grout Inspectio y le�_ Date ' Final Inspection by ll Date Additional Comments: '' �`• ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy X835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO AS '+ EHi3-24{REV.)iKs) - �y! ,.�� .. C.)C� EH 1428 J - - -