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{ : �- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. � 3Z C r Job Address "' K ��'U�Q�-� � City GJ`Tf�C 4CTUMLot Size �Q X 1'L� PM Owner's Name U f4 9 r3 Address .5 2--2-4 IIE JE.V!Ih/ a5 -r-- Phone % a Contractor. Address s2r, License No. / Phone So M 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by r - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is a4 available within 200 feet.) -a Installation will serve: Residence-)(, Commercial_ Other Number of living units: �_ Number of bedrooms kfi Character of soil to a depth of 3 feet: / Water table depth �y J SEPTIC TANK ❑ Type/Mfg [�w��'Is� fa` Capacity 1290001 - No. Compartments ]' PKG. TREATMENT PLT. 0570 Method Method of Disposal, + Distance to nearest: Well Foundation JQ Property Line LEACHING LINE ❑ No. & Length of lines Q Total length/size [� ' ( ! FILTER BER ❑ Distance to nearest: Well�0— Foundation l0 4"� Property Line ' � r SEEPAGE PITS I 1 Depth r.S' Size Number SUMPS ❑ Distance to nearest: Well D Foundation f 40+ Pro .1 perty Line DISPOSAL PONDS ❑ 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. 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 applica ust call for all reinspections. Complete drawing on reverse side. Signed X Title: LO Al� cl%Cl Or Date: FO DEPARTMENT USE ONLY y v Application Accepted by Date L��y� Area Pit or Grout Inspection by Date Final Inspection by Date _ Y Additional Comments: d Q _ 1-1Stk466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 V ❑ Tra4 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 4 RECEIVED BY DATE PERMIT'NO. +.EH 7321IR£V.1/951 EN 11-28 i ✓ I VHU "� �T� I