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i 1 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 " ',(Complete-in Triplicate) I 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. ' City Lot Size PM Job Address i',, � Address to Owner's Name Phone C �Q Gt -s Contractor's Name License No.---2-1 r T Phone p TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION G PUMPINSTALLATION ❑ SYSTEM REPAIR 11OTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 1-1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Specifications ❑ Domestic/Private ❑ Gravel Pack 171 Tracy of Casing g T of Grout ❑ Public ❑ Other [3 Delta Depth of Grout Seal YPe ❑ Irrigation SPP rox. Depth ❑ Eastern Surface Seat Installed by Repair Work Done 1-1Type.�of Pump H.P. State Work Done Vtilell Destruction ❑ Well Diameter Sealing Material (top 50') 1 t Depth Filter Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION CEPA/IR/ADDITION ❑ DESTRUCTION ❑ availableiwthine20D feet.) if public sewer i ..Installation will serve: Residence_ Commercial "'y Other Number of living units: 11 Number of bedrooms 4 l ACharacter of soil to a depth of 3 feet: Water table depth r d Capacity_` Q No. Compartments SEPTIC TANK Type/Mfg— w PKG. TREATMENT PLT. ❑ �'� 1 r t �-* Method of Disposal Distance to nearest: Welt_ - Foundation Property Line i -A LEACHING LINE { LAY Ivo. & Length of lines f— Total length/size FILTER BED } ❑ Distance to nearest: Well' Foundation Property Line ! SEEPAGE PITSf�- 9'pth -Tw Size Number SUMPS ❑ Distance-to nearest: Well Foundation Property 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 I rule`s and regulations of-the San Joaquin Local Health District. s signature certifies the following: "I certify that in the performance of the work for which this permit-is issued, I shall not Home owner or licensed agenfl employ any person in such manner as to'tiecome subject to workman's compensation laws of California." Contractor's hiring-ot sub-contracting signature certifies the following:-� certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa i tion ta of California."The pplica st call, r al egwr , ins tion=COmpletera}wingn everse`si Title: Date:,— Signed AAA Air DEPARTMENT USE ONLY - •' L FOR DEPART , C� Date Area Application Accepted by {i 1`-z` -� / �� ~ ! Date —� Final Inspection by Date Pit or Grout Inspection by 1 Additional Comments: I — { 1:❑ Stk 466-6761 D_Lodi- 369-3621 ❑ Manteca 823-7104 C] Tracy 836-6385 ;Applicant- Return all-copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } CK FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`N0. Y INFO L + EH 13-24 IREV.101831 ' 1J�1tO r'D �'�� EH W28