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h APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED F (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and.the Ryles and Regulations of the San Joaquin Local Health District. '° IM Y'i/ 1 Job Address i City Lot Size 4Z0 4:?,�M 41, Owner's Name Address ❑� �C f�' Phdne Contractor ddress T, 5 G License No.4*_k �>/10 "1 Phone g TYPE OF WELL/PUMP: NEVV WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ __PUMP,INSTALL_A_TION.ID SYSTEM,REPAI_R_L] , �„OTHER_0 T z DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k .INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia..of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 'Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') l Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is t r available within 200 feet.) ' i Installation will serve: Residence_ Commercial_ Other Number of living'units: _1J__ Number of bedrooms 'k Character of soil to a depth of 3 feet: l Water table depth Qi SEPTIC TANK Type/Mfg Capacity d`O l . No. Compartments_ PKG. TREATMENT PLT. ❑ Method of Disposal ti Distance to nearest: Well ` !f ' Foundation [Property Line .- ,_ i ` LEACHING LINE No. & Length of lines ?L"— _ Total length/size G FILTER BED ❑ Distance to nearest: Well +$`U r Foundation_ la Property Line SEEPAGE PITS Depth Size e f Number SUMPS ❑ Distance to nearest: Wel/_C f Foundation Property Line DISPOSAL PONDS ❑ 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 manrievas 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-periit is issed-lshall em to rsons b' t tgyvorkman's compensa tion laws of California." Y I j �'' !1 ,,.� c' The applicant must-call for all required inspe tions_., omplete drawing r6ersYe si 1 S/r 5 Signed s, X � Title: 4 _ Date: {r, I�'S'1 �F�'"'"�"""`� 5�s« �•`.. -`-""`�._ ,�.- FOR DEP,4RTMENT USE ONLY Application Accepted by ` Date t, A'6U - r ` Pit or Grout lnspection-by`-- Qate Final-Inspedtion by D'a'te ` fr Pdiilional Comments; t tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 + # Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE ASH INFO `AMOUNT DUE' AMOUNT REMITTED, C RECEIVED BY DATE PERMIT.NO.. a + EH13-241REV.1/e51 �\ � —Mot � EH 14-26 7�p I