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jig APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address `-' — City St Lot Size PM Owner's Name V- I 0d:: Address Phone ContractorLfE.�--�!Nol !/'-Address is oI Q C icense.No.4'509,0 Phone-L? TYPE: OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ir PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL"T PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑.Tracy* Type of Casing Specifications ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation I ; ---Approx. Depth ❑ Easterner Surface Seal Installed by RepaFr.Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ! ❑ Well Diameter I Sealing Material (top 501 f Depth t Filler Material (Below 501 TYPE: OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ptic system permitted if public sewer is yy available within 200 feet.) Installation will serve: Residence—Cbmmerciaf_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: a Water table depth SEPTIC TANK ❑ Type/Mfg --C-6N c.tr,+I. __ Capacity �J_X)0 No. Compartments PKG. TREATMENT PLT. ❑ ! r ' Method ofD'spQsal Distance to nearest: ulCell Foundation— Property Line (-j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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: "l 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 aa��+fies 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� of California." Th`rpplica ust call f a requ d ins ions. pi drawing o averse side J Signe Title: Date: r �— F TMENT USE ONLY Application Accepted b DateAr a ( go did � Pit or Grout Inspection yDate Final Inspection by Date — �y c Additional Comments: C4 Additional C4 S 'PG e cel a� ❑ Stk 466-6781 ❑ Lodi 3694211 ❑ Manteca -7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services IODI E. Hazelton Ave., P.O. Box 2009, tk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE CASH+ PERMtT`NO . eH 13-24(REV.1/a s) 3S- UU I?--e7 37-- SJ EH W28 wo