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�:.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT •� 1601 E. HAZEL T ON AVE., STOCKTON, CA SCANNED , 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I rJob Address _7 T s. /b-G�'�- -- City Si/nn1r4�)Lot Size +k � PM ner's Name /!-__lT! F�/ j>�lL/ _ A'ddre'ss _ �� `-lV� Phone f'76 Contractor_ u� 4 Address License No. Phone TYPE OF WELL/ PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONS NS ❑ Industrial ❑ Open Bottom El Manteca Dia a Excavation Dia. of Well Casing ❑ Domestic)Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public Cf Other alta Depth of Graut Seal Type of Grout- .--I I Irrigation _Approx. i 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type ump H.P. State Work Done_ Wel! Destruction ❑ ell Diameter Sealing Material )top 50') Depth Filler Material jBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION 1 1 DESTRUC TIO (Nb septic system permitted if public sewer is d a ailable within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ` n SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments V J PKG. TREATMENT PLT. ❑ :, Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L� Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS ❑ 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: "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." e applicant mu all for all require inspections. Complete drawing an� e side. Q� C, ned X Title: _��d� Date: a a r' `•' FORD LTMENTI USE ONLY Application Accepted by ADate 2`2Area Pit or Grout Inspection by a Fin Inspe/C on y Date Additional Comments: � C f �7 ❑ Stk 466-6781 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. INFO +.EH 13-24IREY.t/H51 EH 14-26