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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1 Teiephorte {2091 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JI (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. /n Q •' � E Address C+AV Sao I/LU"IS 11A0 AN J� City Lot Size PM ner's Name 'Q { ��f��A Address � a J L �^^i f�--� Phonentractor C!T• Address License PhonePE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DEST TION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK'— SEWER LINES SPOSAL FLD. PROP. LINE FOUNDATION AGRICUl7URE W OTHER WELL PITS/SUMPS INTEN TYPE OF WELL PROBLE ��RCOINSTRUCTION SPECIFICATIONS❑ Industrial ❑-Open Ma . of Well Excavation 01 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy T pe of Casing " Specifications * Public+ ,~ n Other ❑ Delta' Depth of r Type of Grout I I Irrigation prox, Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ ype of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE.OF SEPTIC WORK: NEW INSTALLATION ["I REPAIR/ADDITION I i DESTRUCTION INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_K_ Commercial— Other Number of living units:.I Number of bedrooms Character of soil to a depth of 3 feet: 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 ❑ No. & Length of lines Total length/size T FILTER BED ❑ Distance to nearest: Well Foundation Property Line d SEEPAGE PIPS 1 1 Depth Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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 tawslifornia." The ap .cant ust a for I r qui d ' spections. Complete drawing on reverse side. Signe X Title: _ l(,e, Date: FOR DEPARTMENT USE ONLY (' Application Accepted"by +Date Area Pit or Grout Inspection ° Date inal Inspoction by Date ,rVt 1 Additional Comments: ��1 r r he"res", or4 `-fes) 4_t(�y ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-63851W-1- Applicant -SApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. +.EH 13.24(REV../K 5) �� tJ LJ 6D o,G-as '4`LI EH 14-2a