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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) s 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 4 Local Health District. u. I Job Address �- Cit of Size 1 R Owner's Name L-=- ` '" AddressPhon j y e - " Contractor's Name fz IALTJD41_•,_License No. Phone I 'TYPE OF WEtNEUAIREST- MP: NEW WELL ❑ w WELL REPLACEMENT ❑ DESTRUCTION ❑ i" xPUMP;INSTALLATfON ❑ � SYSTEM REPAIR ❑ OTHER ❑c'jDISTANC_TSEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca-1 Dia. of Well Excavation Dia. of Well Casing k El Domestic/Private E3 Gravel Pack Tracy , Type of Casing_ Specifications F- ❑ Public ❑ Other, f ❑ Delta Depth of Grout Seal Type of Grout �❑ Irrigation --Approx.'.Depth ❑ Eastern• - 'Surface Seal Installed by El Repair Work Done ❑ Type of Pump � �H.Pt-i State Work Done ;Well Destruction ❑ Well Diameter Sealing Material Itop 501 ' I Depth J_ — - — —Filler-Material-Melow 50') - f f c. TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION El DESTRUCTIONS 13 (No septic system permitted if public sewer is } available within 200 feet.) _ a � 4 Installation will serve: Residence Commercial ther Number of living units:__L_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ISEPTIC TANK ❑ Type/Mfg Capacity Z P'l No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal } Distance to nearest: Well Foundation Property Line i ,LEACHING LINE &I< & Length of lines mn Total length/size FILTER BED ❑ Distance to nearest: Well lA Foundation ""`"'Propert}+'L'ini3 WISEEPAGE PITS Er Depth Size M3 (p ) Number SUMPS ❑ Distance to nearest: Well Foundation `�t\ Property Line [DISPOSAL PONDS ❑ t I hereby certify that I have prepared this application and that the two rk will be clone in accordance with San Joaquin county ordinances, state laws, and {rules and regulations of the San Joaquin Local Health District. I .A �'3 r ` I 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 Miring or sub contracting signature ace ' 'es 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- Etio Ia California." The lica t m call for al required ins�tions �omsdrawing o reverse si j FSigned Title: Date: n r OR DEPARTMENT.USE ONLY -7 X !Application Accepted by { Date A. Area Q r ir1 i Pit or Grout Inspection by r Date �� Final Ins ction by �L pate t Additional Comments: ' 11,11 i❑ Stk 466-6781 ❑ Lodi 369-362V ❑ teca 823-7104 J f Y 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 H RECEIVED BY DATE PERMIT"NO. l INFO ]G� f� —4 +EH 13-24{REV.101831 SKI IV 0 /"1 `•' r �� EH 114-26 3