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�t3 / Mrd ' APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR 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 (� Q /H - City Sp`s� Lot Size � e✓h� PM Owner's Name / '� `LAddcess �� �G `� � Phone - - Contractor � " ' " Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER'LINES - DISPOSAL-FLD7='-- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca _Dia. of WWI Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy, 4.r Type of Casing Specifications ❑ Public z ❑ Other ❑ 'Delta; Depth of Grout Seal Type of Grout ! _ I I Irrigation ___.Approx� Depth l I Eastern Surface Seal installed by _ Repair Work Done L] Type of Pump H`P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth f Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION Ilk'' DESTRUCTION I i INo septic system permitted if public sewer is f available within 200 feet.l Installation will serve: Residence X Commercial i Other �-- - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet!___ A-A?d,6/- Water table depth SEPTIC TANK ❑ Type/Mfg, Capacity /j e,-C;, No. Compartments _ PKG. TREATMENT PLT. ❑ 1 J Method of Disposal Distance to nearest: Well l` Foundation Property Line s � , LEACHING LINE No. & Length of lines — Total length/size FILTER BED ❑l Distance to nearest: WellFoundation Zu �qk_- Property Line_...__._.7 SEEPAGE PITS i I Depth _Size r Number SUMPS Ll Distance;f to nearest: Well if r„� Foundations Property Line DISPOSAL PONDS El �-J 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 rules and regulations of the San Joaquin Local Health District. k # 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:._)_certify-that.in-the.perfotmance.of-the--work for which-this-permit.is,issued,.I.shall.eI ploy_personssubject to-workmanlcompensa- tion laws of California." L The applica9 u apn all for all required inspee s. Complete drawing on reverse side. / Signed X 'g-z- Title: li7/i!�,�/L Date: FOR DEPARTMENT USE ONLY I Application Accepted by Date Z4- Area i Pit or Grout Inspection Date Final Inspection by-6�� w— `�" Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ 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 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. s ♦ EH 13-241REV.1/H 5) • 00 1-7,P -93 ��Z�S oda EH 14-2e —70 �� 1