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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) �� ^z \� VVA Application is hereby made to the San Joetin 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 Sari Joaquin 1 Local Health District. Joh Address / T� o City Lot Size PM J � est 'Owner's Name ' Address / ` I e Phone Contractor n5 n s Address + O�.License No. �d Phone �� f 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 1! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� i ❑ Industrial 17Open Bottom Manteca ;Dia..of(Nell-Excavation—--- - Dia- of Well Casing l� ❑ Domestic/Private ❑ Gravel Pack e ❑ Tracy Type of Casing-A Specifications t k. ❑ Public ❑ Other L ❑ Delta Depth of Grout Seal Type of Grout l ❑ Irrigation _—.Apprdx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Ll Type of Pumpr` H.P. i .State Work Done Well Destruction ❑ Well Diameter�F v Sealing Material (top 50') '� r Depth i Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Others _111- Number of living units: Number of bedrooms (' ; Character of soil to a depth of 3 feet-. + € i Water table depth 1. ! ka' SEPTIC TANK ❑ Type/MfgJ Capacity i No'Compartments PKG. TREATMENT PLT 17 # ` Method of Disposal 'E Distance to nearest:: Well t Foundation Property Line . 4 LEACHING LINE El No. & Length`.of lines _ Total length/size §� FILTER BED LiDistance-to nearest: Well t Foundation Property'Line 13 SEEPAGE PITS EJ Depth kt Size Number SUMPS k ❑ -Distance'to nearest, Well L Foundation E 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 shah 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 employpersons subject to workman's compensa- tion laws of Armcall ." The applicanfor all required inspections: Complete drawing on reverse sift Signed X Title: — Date: or L �> j FO D PARTMENT USE ONLY .L Application Acceptedby Date T` S`' Area Pit or Grout inspection by Date Final Inspection by - Date mow/ P - j a n Additional Comments f°C�-�� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 ' 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 CK RECEIVED BY" DATE PERMIT NO- INFO _ 3 3s 23 3 t [ � + EH 13-24 TREY. /ti 51 s-0 6 { EH 14-26 -