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�! E APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED I (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. 11 Job Address o City � /� _ Lot Size Zd4W6 PM �is�L Address � Phone Owner's Name I it ContractorLL7Il'f L Address /1/ License26 License Nv. Phone TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR 17' OTHER ❑ t �. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE [tom FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE JYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial C&Qpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VIDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications A 1 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. Depptth�� ,ISI Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H P• State Work Done T Well Destruction ❑ Well Diameter Sealing Material (top 50') ' Depth (�-�� Filler Material (Below 50'I — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) �\ J Installation will serve: Residence— Commercial_ Other r� Number of living units: II Number of bedrooms + U Character of soil to a depth of 3 feet: Water table depth r ; SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ iI Method of Disposal Distance to nearest: Well Foundation Property Line Ir LEACHING LINE ❑ Na'A Length of lines Total length/size �' 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line !I l SEEPAGE PITS I I Depth Size Number l SUMPS ❑ Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ II 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, y 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: "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 st c quired inspecti9gs. Complete drawing on reverse side. t �� ._ r ��) ,. Signed X Title:� /�l� Date: � �! I FOR DEPARTMENT USE ONLY 1 1 Application Accepted by i Date 9—V3 Ara i_L Pit or Grout Inspection by ' Data Final Inspection by Date it Additional Comments: ❑ Stk 466-6781 ❑ Lodi [369-3621 ❑ Manteca 623-7104• ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CAySyHy�-)y RECEIVED BY DATE PERMIT NO. +,EH 13-24 IREV.1/H 5) 'l 60 EH 1428 i, I