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. . F x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED yt (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 r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well pump and the Rules and Regulations of the San Joaquin. Local Health District. IJob Address _... _.lel gLL Y/L c'��// _ City Hoil Lot Size PM i t "Owner's Name Y1 6'J10SfWV HA Address Phone Contractor U C. Address . T License No. f-z99o/ Phone 7 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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C] Public [I Other ❑ Delta Depth of Grout SealType of Grout F f' ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by l\v t� 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 ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence_ Commercial—iZ-Other Number of living units: Number of bedrooms ti Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg (15,"17le Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .Distance to nearest: Well Foundation Asa Property Line_35:! 1' 1 'LEACHING LINE Cr�No. & Length of lines 0 36'' Total length/size 6 to FILTER BED ❑ Distance to nearest: Well oundation Property Line f r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 j 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." The applicant must call for all required inspections. Complete drawing onreverseside. r Signed T Title: fi&a!unt� Date: FOR DEPARTMENT USE ONLY t Application Accepted b Date Area d + Pit or Grout Inspection by Date Final Inspection byA/zDate Additional Comments: ND D f U 1 A! UIe 0* PAte KJC-Q �*ACt4 CbLp k❑ Stk 4664781 El69- Lodi 33621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 L Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED tASW RECEIVED BY DATE PERMIT NO. + EH 13-24IREV.i/est fl -7 /�11p -roll 14-28 6