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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address —6— 7 q/J ��© � I �� L - itY `� m- Lot Size PM Owner's Name Address ! t5 Phone Contractor lJl 1 L�BRILL- Address� U 1A,J.�.f'E ItOl_icense No.� 1�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C7 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 PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications G M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout \ I Irrigation —Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I TRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence�mmercial— Other Number of living units: I Number of b ro ms _ Character of soil to a depth of 3 feet: `"D �� Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L9--1q5- & Length of lines t g Total length/size. g FILTER BED ❑ Distance to nearest: Well L Foundation Property Line ��i•- SEEPAGE PITS 14--—Depth Size r� a Number r SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ / U 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 \p rules and regulations of the San Joaquin Local Health Diltrict. r� 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- n laws of California " Thea nt mu t c II r ail lquir in s. Complete d rawing reverse side. Signed Title: Date: _ FOR DEPARTMENT USE ONLY Application Accepted by date 2 -�Z Area r! Pit or Grout Inspection by Date Final Inspection by Z Date+�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Sarvices 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 FEE INFO AMO�U9NT DUE AMOUNT REMITTED CASH CK T' RECEIVED BY DATE PERMIT'NO. +.EH 13-24iREV.1/951 �!/ 3��g � /yy EH 14-25