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. . •.• APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. r /� �f c < Job Address 7_—"_s_1i �Z,S��[/�rd City s Lot Size.�� a aa C7 PM Owner's Name Address G3 d 5 � � � Phone 7` 07, 7 Contractor Address'/1, _�'l'�,�� License No. 3.001Q Phone 21 TYPE OF WELL/PUMP: _ NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' ` 60" SEWER LINES DISPOSAL FLD.�.`•�bROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indu ❑ Open Bottom ❑ Manteca. Dia- of Well Excavation Dia. of Well Casing .mastic/Private ravel Pack C] Tracy Type of Casing �M�' /,� O Specifications n Public Fl Other Cl Delta Depth of Grout Seal • Type of rout I I Irrigation —.Approx. Depth I I Eastern Su face Seal Installed by w _ Repair Work Done ❑- Type of Pump r H.P, Z ;i0 State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 sfi TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION 1.1 DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet_.) Installation will serve: Residence= Commercial— Other Number of living units: Number of bedrooms Charactdr of soil to a depth of 3 feet. Water table depth SEPTIC TANK ❑ 'Type/Mfg` Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal i { r Distance to nearest: Well Foundation. Property Line LEACHING LINE ❑ No. & Length of lines Total length/size '�.-FiL-T£R 'BED ❑ Distance to nearest: Well Foundation Property Line SUMPS, L7 Distance to neares�"�-Well _Foundation Property Line DISPOSAL PONDS ❑ _ �...v. I hereby certify that I have prepared this application and that the work.will be done in accordance with Sari-Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Al i' '. '�t\', - 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 w_hick this permit is jssued,.I.shall employ.persons subject to workman's compensa- tion laws of California." The applicant mu t call for all required inspect Complete drawing on reverse side. } Signed X_:2 �� Title: Date: r � FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspectio Date 1A Final Inspection by Date f Additional Comments: 1 ' ❑ 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 FEE' INFO' AMOUNT.DUE ` � CK A -AMOUNT..REMITTED—. '=C SH __RECEIV D BY • ---DATES-+�*-', —PERMIT=110-- ^a +.EH13-24IREV.1/8514�� EH 14-26 " +r C//—U