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My 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 �11 (Complete in Triplicate) SSG o L d tf 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 Reputations of the San Joaquin Local Health District. `N� �) —�7 Q t C&,Z( / i Job Address / City Lot Size jw X l< _PM Owner's Name !/1 P � Address V ' y Phone 6 G~ 6 Contractor Address License No. Phone TYPE OF WELLIPUMP: 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' F1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth i I Eastern Surface Seat Installed by _ I Repair Work Done 0 Type of Pump H.P. State Work Done _ Ilk Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I OESTRUCTIO INo septic system permitted it public sewer is i available within 200.feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity—L-- No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengtWsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with $an.Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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 j 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 which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 'The applicant Tilpt call for uired inspec i plate drawing on reverse side. �L Signed X Title: 0 rQ c r Date: �� Arr 7 FOR DEPARTMENT USE ONLY Application Accepted by Data I Area Pit or Grout Inspection y/ Date Final Inspection by Y ` '' Date Additional Comments: ! r uf? u 7 / �� O V""- ;., a ��G r ❑ Stk 466-6781 ❑ Lodi 369621 ❑ nteca 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 AMOUNT REMITTED CK RECEIVED BY DATE PERRMIT*NO. +.EH 13-241AFV.1/H5) �S� �.7 �� ti �lJ F �♦ � EH 14-28 C7