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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 !! s (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. E { Job Address `y � /f/J (/t�Gf. City Lot Size C30 ,PM Owner's Name Address t -�-E=�L Phone d y !!! Contrac r Address License No. 2eZZ Phone_ --5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i t 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing ' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 \� TYPE OF SEPTIC WORK: NEW INSTALLATION I—REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available withip 200 feet.""h � � Installation will serve: Residence ✓ Commercial— Other OLV'1tiAA � �s'F""-" Number of living units: /. Number f edrooms..c2 f I `. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK FI- Type/MfgCapacity � -0 0— No. Compartments - PKG. TREATMENT PLT. ❑ \. r Method of Disosal p �--+ Distance to nearest: Well.1 o Foundation � Property Line yQ 41 LEACHING LINE PT'�No. & Ler4th of lines Q X - r� 9 !' Q Total length/size � FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS, (�r' Depth f Size 3 Number - {1 SUMPS ❑ Distance to nearest: Well Foundation &36„` Property Line "IQ DISPOSAL PONDS .2 . ' 1 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 r,'egulatlons 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 becorTI subject to=workman's compensation laws of California.”Contractor's hiring or sub-contracting signature y.r certifies the following:_I-certifythat.in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- ytion laws of California." l # The,applicant ust-call f all-1 aired inspections. Complete drawing on reverse sid . Signed . Title-�. Date:- �' ` # --- � �FOR DEPARTMENT USE ONLY Application Accepted liy- ,R. Date Area ` -. .._ _ _ Pit or Grout Inspection by Date Fnal Inspection_by Date . -- Additional-Comments:--- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 u Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �� DATE PERMIT'NO. + EH1 -24IREV.S/e51 � S -Ci EH 1428 • `o