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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 TYEAR FROM DATE ISSUED } (Complete in Triplicate) III r t 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 186 for I/pump and the Rules and Regulations of the San Joaquin Local Health District. Q /vCJ i f Job Address 9 zjw 4 !! City,&l2f,4Lot Size Pty Orr t �!�_^� e I Owner's Name ,-"'d �i_,_.,`?, �"w! Address Phone Contractor tH Address u License No.420 Phone ✓ �`7r TYPE OF WELL/PUMP: ,� v_ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - 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 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i} { F] Public n Other I n Delta Depth of Grout Seal Type of Grout I I Irrigation ---Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ! Well Destruction L1Well Diameter] Sealing Material (top 501 Depth j Filler Material (below 501 j TYPE OF SEPTIC WORK: NEW INSTALLATION 1111 REPAIR/ADDITION IJ DESTRUCTION I I (No septic system 'permitted if public sewer is � I� available within 200 feet.) �J Installation will serve: Residence Commercial_ Other Number of living units: —I-- Number of bedrooms-F3 -.,— Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 1 No. Compartments PKC. TREATMENT PLT. ❑ ° T Method of Dispo§.@l Q ' Distance to nearest: Well Foundation l9 Property Line F. f 4 LEACHING LINE ❑ No. & Lengt_h of lines .t ,Total length/size FILTER BED ❑ Distance to nearest: Well Foundation__. _ Property Lime SEEPAGE PITS I l Depth V!�� X._ .�dre I Number UMP 0 Distance to nearest: Well Foundation o.D 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mariner 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,1 shall employ persons subject to workman's compensa- tion laws of California." r The applicant must call fo all req ed nspections. Com ate drawing on reverse side. . Signed _4�q Title: ( Date: FO DEPARTMENT USE ONLY Application Accepted by W1 I& Date Area Pit or Grout Inspection by Date Final Inspection by Date 0�4� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environm=ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t _ INFO AMOUNT DUE AMOUNT REMITTED AI. CASH CK 4 RECEIVED BY , } DATE PERMIT NO. # * EH 14-261REV.1/x51 S'v t Q m� th �,q,q - i