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APPLICATION FOR PERMIT l SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA RECEIVED Telephohe ) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED jUt 2 19�� (Complete in Triplicate? ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the wop TAAM16 f Nfl"9_his 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. /l� Job Address � ,`�/ City uL(�r17'U Lot Size PM Owner's Name Address ticoo G Phone Contractor 6 iT __ Address ea—License No.cJ O§� Phone CJ 43f9_3 TYPE,' F WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTtNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial : ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private E7 Gravel Pack ❑ Tracy Type of Casing Specifications l`l Public ❑ Other f l Delta Depth of Grout Seal Type of Grout, t I irrigation _Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done _ Well Destruction LJ 'Well Diameter Sealing Material (top 50') X Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ILK REPAIR/ADDITION I ) DESTRUCTION 13 INo septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Re 'dente Commercial_ Other r Number of living units: Number of rooms Character of soil to a depth of 3 feet: — Water table depth ez + 1y -t E SEPTIC TANK Type/Mfg kk Capacity No. Compartments PKG. TREATMENT PLT. E] f r' Method of Disposal t Distance-to nearest: Wett Foundation �Q Property Line / v LEACHING LINE & Length of lines f - Total length/size I FILTER BED } ❑ Distance to nearest: , Well Foundation J 01 Property Line '�7 f .t SEEPAGE PITS I�Depth ,?6Size _ y r f� Number .Z-t 1 ✓ r SUMPS Ll Distance to_neafest Well I� � I Property 4ine Foundation DISPOSAL PONDS O ' r' 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 signAure 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 must tali for :l1�dtions. Complete drawing on reverse side. i Signed X j r Title: _S�VC* Date: ;,2,6 FOR DEPARTMENT USE ONLY Application Accepted by Date U Area ? r ## Pit or Grout Inspection by _ Date Final Inspection by ` 1 Date,3 Additional Comments: ❑ Stk 466-6781 _ ..0 Lodi- 369-362-1 ❑ Manteca. 823-7104----Q-Tracy 835-6365—... _ Applicant -Return all copies to: Environmental Heatth Permit/.Services 1601. E.Hazelton Ave., P.O. Box 2009, Stk., CA 957P:ER 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE MIT'N0. INFO +-EH13-21(REV. � EH 14-26 7 L7