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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (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. Job Address /�I-5 0\ City S+ Lot Size Sa X l to PM Owner's Name Eau 12 r q 5Q[ ' h Phone 'f 76 —OaqO, Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i 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 IXC"---WE-Lt '"" PROBLEM'A�REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing c ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy f. Type of Casing Specifications FI Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ ' I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. _..State Work-Done_ _ - I Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: .NEW INSTALLATION I I 'REPAIR/ADDITION I i_DFSTR.0CTI 0N- . .(No septic..system,.perrriitted.if public sewer is ' "available within200 feet.)`-" Installation will serve Residence Commercial— Other + I Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity---L— No. Compartments PKG. TREATMENT PLT. ❑ o!- - Method of Disposal,' Distance to nearest: Well Foundation PFoperty Line-. I LEACHING LINE ❑ No. & Length of lines 1 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 ) t SEEPAGE PITS I 1 Depth Size != Number SUMPS ❑ Distance to nearest: Well Foundation _ 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 I rules and regulations of the San Joaquin Local Health District. s 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 lawsrof California." Contractor's hiring or sub-contracting signature i 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." I The applicant mutr" 11 for all requir i pections. Complete drawing on reverse side. 1 c Signed X . y✓ i t ` Title: z ..:.rfo Date: _ * i I FOR DEPARTMENT USE ONLY,,-•��-� -x-...�,..,,, r Application Accepted by `tt, "7,.•e .,., Dates �f- 7 = Area Pit or Grout'Inspection by Date 'Final Inspection by Date Add itiona4l Comments: Mc,, �`t rt f s' t?/ 9✓1. . s � ..:a+" Y r • t r ❑ Stk M6 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant— Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE l _ INFO AMOUNT DUE AMOUNT REMITTED CA K RECEIVED BY DATE PERMIT NO. I / (\� \\}} / `n/ +.EH 13-24(REV.iin5) (JU .)`Jt �l.! / .�J� _^",.+a _ -_ EH