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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I � 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 L A) City Lot Size PM o Owner's Name I��IifG �.t/ I _ Address �� T ,4�1_ Phone �l Contractor's Name License No.;— r1. Phone -;2� 1< TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT!❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR; ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ! 1 DISPOSAL FLD. PROP. LINE fiOUNDATION AGR►CULTURE-WEL-L------ ; OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM�A`REA: CONSTRUCTION SPECIFICATIONS` ❑ Industrial ❑:Open Bottom F-1 Dia.-of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0!Gravel Pack ❑ Tracy < Type of.'Casing - Specifications 11 Public ❑!Other I ❑'Dalt;e I Depth of Grout'Seal.s, Type of Grout N ❑ Irrigation �pprox. Depth A Eastern � Surface Seal Installed-by � 6 Repair Work Dane ❑ Type of Pump l H.P. F— ! State Work Done Well Destruction ❑ Well Diametier + Sealing Material itop 50T P } Depth ! +, q s .F�llar Material (Below 50'1. n TYPE OF SEPTIC WORK: NEW INSTALLATION,O REPAIR/,/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re{idencell Commercial_Other , Number of living units: Number of bedrooms k Character of soil to a depth of 3 feet: A DO13it.✓ Water table depth 6 �� SEPTIC TANK © . Type/Mfg Capacity 0lv UPJ No. Compartments 4� PKG. TREATMENT PLT. ❑ ` f f` �` Method of Disposal Distance,to nearest: �` 1/4eIE Foundation Property' ro ertLine — LEACHING LINE ❑ j No. & Length of lines ` /�u_�� a3��` --'Total length/size g9 1 :r7 , + FILTER BEDDistanceito nearest: Well� Fou dation %G 16 Property Line /2-7 SEEPAGE PITS ❑ Depth Size. "Y — Number-SUMPS ❑ Distance ito nearest: Well 1 Foundation Property-,Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application-.and that the*ork will-be-done-in.acco_rdance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. , r 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 coml ensatlon 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 call for al! req ui d nspecttons'Complete drawing on reverse side. Signed X //`� ' ' tee au^-'• Title: -Date: i FOj,Ri D�ARTMENT USE ONLY I Application Accepted by l � P` Date ~/ Area Pit or Grout Inspection by x Date Final Inspection by Date '' 3 Additional Comments: ❑ Stk 466-781 ❑ Lodi 36_3-3_621 I ❑ Manteca_BM-7104_ _ O.Tracy- -835.6.385 Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEK. INFO AMOUNT DUE� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. ♦ EH714-28 3-24[REV.101831 EH / - x_ f "+z icy �S5 ' t�