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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11,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. / C 4�elc 7eE1 vl/ , /�"�, z Job Address Cit /� Lot Size 6 E PM S 7UC�rO,N C� 9._S�O�Phone - "Y�Z �YE�✓ 3�// �[/ rY°9 �/liE Owner's Name Address3//V � Contractor 7�Address T C,02)r lOS ��p�,/_' _ License No. '_/Ag,3�_1 Phone 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 SPECiFiCATI0IYS ..cam-.. .. t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing Specifications n I'I Public CI Other n Delta Depth of Grout Seal Type of Grout -.,- I I Irrigation _Approx. Depth 1 1 Eastern Surface Seal Installed by PAYMENT VME., Repair Work Done ❑ Type of Pump H.P. State Work Done — ► r'►r^r ,.�s Well Destruction ❑ Well Diameter Sealing Material Itop 501 62 I.All Depth Filler Material (Below 501 MAY u Inn±- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is III available witAirti�ieet I Installation will serve: Residence— Commercial_ Other .CC�IVV {U MENTAL HEALTH Number of living units: Number of bedrooms pERMITISERV(CES Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Progeny Line f>'�}'l.'YR'y/OiV/5 ��"�A'G1�tr/•�F7Yl.,s�..GYGYf'K.FL!>'✓f1.�JS��✓1�:3-c.I,`4�i'%T�7'TCJ/�t/D t?.�rPyf'OY�"a�i l� '`�TLf/�;!% •'. LEACHING LINE Cl No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I 1 Depth Size Number _ SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 F rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:g g g: "1 certify that in the performance of the work for which this permit is issued, 1 shall not k employ any person in such manner as to become subject to workman's compensation laws of 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." The applicar,4 mtf cal for II quired inspections. Complete drawing on verse side. t g Signed X 7N Title: Date: FO ARTTPEWUSIE ONLY Application Accepted by Date �y a Pit or Grout inspection by Date Final Inspection b ate 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 FEE INFO AMOUNT DUE AflV1011 T REMITTED CA RECEIVED BY DATE PERMIT"NO. .. EH 13-24(REV.1 r n 5) k EH 14-26 r Ud tLj Z3 Lf