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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA j' Telephone (209) 466-6781 !t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' (Complete in Triplicate) kT , . 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 i 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. w ��. 0, Job Address CityLot Size PM ;Owner's Name Address Phone ow Contractor -fh• �UL'GC - Address ! v+ i � License Nox07?7$6�-� Phone v e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT(❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ SYSTEM REPAIR,❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP.'ILINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS --� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other? ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation a —,—Approx. Depth LJEastern Surface Seal Installed by Repair Work Done} ❑ Type of Pump H.P. State Work Done Well Destruction ❑" Well Diameter } Sealing Material (top 50'? Depth Filler Material [Below 501 TYPE OF SEPTIC WORK:,-NEW INSTALLATION- REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is r�j f available within 2170 feet.) - _ Installation will serve: Residence,l�•. Commercial_ __Other ;1 if Number of living units: _ Number of bedrooms 3 _�" s Character of soil to a depth of 3 feet: - G Water table depth SEPTIC TANK ❑ T e/Mf YP 9 - P�^L Capacity- No. Compartments � PKG. TREATMENT PLT. q �-— Method of Disposal f ' — Distance to nearest:__Well Foundation Pro ert Line ;...-. ::lis- Property y 5 LEACHING UNE L No. & Length of lines F� ? Total length/size ' 3oa ,a FILTER BED ❑ Distance to,nearest: Well. Foundation 4 F"T^Property Line 3, Q ' I SEEPAGE PITS ❑ Depth n -s SizeNumber SUMPS C1Distance to nearest: WeA. ll Foundation- Property Line DISPOSAL PONDS ❑ # I hereby certify that.1 have prepared this application and that the workwill be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District. C� Home owner or licensed agent's signatui4certifies"the fbllowing: "I certify that in the•perfbrmance of the work for which this permit is issued, i shall not employ any y person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature > certifies the following: "I certify that in theperformance 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 must call for all r wired in specti'ons�Complete drawing on reverse side. � I Signed X E + ` x -�— Title: Date: Y �.. { FOR QIEPARTMENT USE ONLY ; } Application Accepted by ' pate Area �- Pit or Grout Inspection by Date Final Inspection by Date Additional,Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621; ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 e � I i 5 FEE AMOUNT DUE AMOUNT.REMITTED CK# RECEIVED BY, r,mDAT.E —PERMIT'NO. i _INFO -CASH- P + EH 13-24(REV.1/8E) �.' 5-0 5 1� '.fir_ `� EH`14-26 -*r--•:'i+ �..,q=r:-s -�--+`*�-- -^ �,r..""^'��,.-` LL