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APPLICATION FOR PERMIT �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 1 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. 7 7 Job Address �/1 �)-` RU Zdd City Lot Size- Z4 PM .c Owner's Name Address Phone ` Contractor f7 CJ/(3 P Address �gt��/o lo, , License N&Za4;f; � Phone l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other5( El Delta Depth of Grout Seal Type of Grout_ i 1 ❑ Irrigation --Approx. Deptji ❑ Eastern Surface Seal Installed by - V- Repair Work Done F-1Typeof Pump- - R.P.--�- "\ %+T State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLA LION �❑-,REP,AIRY-ADD1TION ❑ IDESTRUCTION ❑ (No septic system permitted if public sewer is available within 2W feet.) 4 a\ l� + Installation will serve: Residence_ Co'?nmercial Other _ Number of living units: -�Number of bedrooms 4 Character of soil to a depth of 3 feet::. l Water table depth SEPTIC TANK ❑ Type/Mfg r} j� Capacity__._�1�No.�Compartments PKG. TREATMENT.PLT. ❑ ` 'm" - _ - -i �Method�f Disposal Distance to nearest:-----Wetl'.�__ Foundation Property Line.- _ ' ' LEACHING LINE _ � No. & Length of lines ��._� !Y � .�- Total length/size FILTER BED El Distance to nearest: Well Foundation t") Property Line rf7�a �6d� SEEPAGE PITS ❑ Depth Sizej Number a SUMPS ❑ Distance to nearest: Well Founldation Property Line DISPOSAL PONDS ❑ i 4 1 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. I 1 Home owner or licensed agents signature certifies the following."I certify,that in_the.�erformance of the work for which this permit is issued, I shall not employ any person in such manner as to became subject to workmaWi compensation laws of California." Contractor's hiring or sub-contracting signature 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." The applicant ust call for all required inspections. Complete drawing on reverse si e. C� Q Signed X / � Title: ' Date: -/ FOR DEPARTMENT USE ONLY i i . Application Accepts y Data Q Ir1r ` —1?/6�/�� Areal � f�A. Pit or Grout Inspection by Dates-- - --=final Inspection by/ v//�`-sr G`�Z� Date �a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354085 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 CASH RECEIVED BY DATE PERMITNO. INFO Q�]/v r EH 1324{REV.1/e 57 EH W28 O