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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT Y . f 1601 E. HAZE T ON 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. .e Job.Address 4 / 37" d'/7' IP�i�i�� o& City_� Lot Size PM Owner's Name Fit.^i11g7'SftlT�— ia�f � /Z ,t r, xSp��Phone �7 " Contractor Address j a License No. .2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION f*&�-jaSYSTEM REPAIR ❑ OTHER L1 -DISTANCE TO NEAREST:.SEPTIC TANK ..- SEWER LINES DISPOSAL FLD. PROP. LIN£. FOUNDATION AGRICULTURE WELL OTHER WELL I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEOIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation' ( Dia. of Well Casing r Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing r j Specifications f"I Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout r I Irrigation Approx: Depth; I I Eastern - Su face Seal Installed by _ j Repair Work Done L7 Type of Pu " H.P. ! tate�Wbrk Done!L 12W: Well Destruction ❑ Well Diameter Sealing Material atop 5011r Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION ( ]'(No septic system permitted if public sewer is 'V i available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms i t q Character of soil to a depth of 3 feet!' /1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity j '\49 No4 Compartments PKG. TREATMENT PLT. ❑ r Method of"Disposal r Distance to nearest: Well Foundation .Property Line' r; LEACHING LINE ❑ No. & Length of lines Total length/size - , •ti k FILTER BED ❑" Distance to nearest: _ Well k Foundation .Property`Line �A u. SEEPAGE PITS l I Depfhj Size _ Number " '" �Sl11tifPS'�' - y–L� Dist n3 ce ta7twa-r-6st � Foundation' "'j Pioperty,Line DISPOSAL PONDS ❑ C\ I hereby certify that Ihave pteparedthrs app3icatio a d that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaq�in Local Health District. I 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 } p y an y person in such manner as to'becnmetsubjbct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfbrmnce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ; The applicant o al! requir=,' ns. mplete drawing on never side. Signed X Title: I Date: / FOR DEPARTMENT USE ONL Application Accepted by bate Z Area Pit or Grout Inspection by Date Final Inspection byZ�Jlb791 Date J� Additional Comments: t T t ❑ Stk 466-6781 " ❑ Lodi -369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 Applicant- Return all copies to: Enviror6ental Health Permit/Services 1601 E. Hazelton Ave. -P.O. Box 2009, Stk., CA 95201 .. � FEE INFO AMOUNT DUE r AMOUNT REMITTED CASH RECEIViD By , DATE PERMIT"NOfH 13-24 . f (REV.1/n 51 EH'14-28 �� TM �Z' I � C�