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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 No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address /_ �� &Xein- ten. Lot Size PM ►3aQ� E [�� Phone 77C2: —�w—rc0 Owner's Name` Address � r _P.© &xtc"1 I�� .o-o� v 3Q 8a a 6 Phone load�5� Contract Address z _ License.No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS _ 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ~T ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation •\. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public ❑ Other L-] Delta Depth of Grout Seal f Type of Grout __ I I Irrigation _____.Approx. Depth I I Eastern Surface Seal Installed by s _ Repair Work Done ❑ Type of Pump H.P. -r' State Work Done Well Destructions ,D_„'Well.Diameter Sealing Material (top 501 Depth -' ,� 91ler�Mate rr al (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other ' Number of living units: —I— Number f edro_ s_' �+._-_ 0,6Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ➢9r Type/Mfg r ( Capacity X10100 No. Compartments PKG, TREATMENT PLT. ❑ Y u f--�- -----' I / Method of Dis p osal Distance to nearest: Well Foundation Property Line S r1 f LEACHING LINE u x No. & Length of lines �� Total length/size FILTER BED ❑ distance to nearest Well % _vFoundation �� Property Line s SEEPAGE PITS V7+ Depth Size _f Number f SUMPS ❑ Distance to nearest: Well,_Q0.,_. Foundation_.._10 Property Line J� DISPOSAL PONDS ❑ Y I hereby certify-thauhave-prepared-this-applicatiop,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 Heakh District. LL 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." The applicant ust call f all ra ired inspections. Complete drawing on reverse side. .. „Signed'X` T Title:-" ,.._— .:.��±�•�:. .- . _ -,..-,..--,_..-.,._.-Date: [0��:�� i�- FOR,DEPARTMENT USE ONLY- }' ,. Application Accepted by Pit or Grout Inspection by Date Final Inspection by Date/fes+ _&A_5 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' 1 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 CASH CK RECEIVED BY DATE PERMI7'NO. r s.EH13-24 IREV.1/R 53 I cyrA EH 14-26 'b��