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f APPLICATION FOR PERMIT r �S SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED Application is hereby made to the San Jo (Complete in Triplicate) aquin 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job Address S: Q t p �7d c% �.,� City" Lot Size PM Owner's Name Address g S. p�(,✓ y 6 ^�7S� _ — Phone Contractor_ + Address TYPE OF WELL/PUMP: License No. Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE�WELL --OTHER—OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.,SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. 04 Well Excavation ❑ Domestic/Private ❑ Gravel Pack Cl Tracy - Type Dia. of Well Casing of Casing 1 M Public 171 Other Cf Delta Specifications _ depth of Grout Seal Type of Grout I I Irrigation -Approx. Depth { ('Eastern 1 ' Surface Seal rrisiailecl by Repair Work Done ❑ Type c# Pump: H P _ State Work Done Well Destruction ❑ Well Diameter _ Sealing Material ftop:50'1 Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW-INSTALLATION I] REPAIR/ADDITION I I utZ3 I KUCTIONX Mo septic systemermined it G public sewer is Installation will serve: Residence - ' Commercial Other available within 200 feet.) _' Number of living units: Number-of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK j r Water table depth i ❑ Type/Mfg Capacity _ NoLth-d N PKG. TREATMENT PLT. 0 # f r Mel Distance to nearest: Vl/elf Foundation Property' LEACHING LINE ❑ No. & Length of line's r $ Total length/size Lil FILTER BED ❑ Distance to nearest: Well Foundation Property SEEPAGE PITS I I Depth t Size I� SUMPS Number ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property line I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin'Lgcal Health District. P w 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 must cal! r all re d inspections. Complete drawing on reverse side. Signed X Title: - Date: " � FOR DEPARTMENT USE ONLY I -Application Accepted by t, Date Area_ 4 Pit or Grout Inspe on b Date Final Inspection by �✓ i I Date Additional Comments: Il �Yr+ti�f j i/ �Z(j111 2 U 4, EJ Stk 466.6761 13 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 7� FEE AMOUNT DUE AMOUNT REMITTED CK INFO �7� $ '�� RECEIVED 13Y DATE PERMIT'NO. + EH14-24iREV.rinsl S.LJU `1 3s,f.�r� EH 1A-2fl 1 ZJ 1 �