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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"H— LTH DISTRICT r 1601 E. HAZELTON+AVE.,11STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ` Application Whereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. p r as .� Job Address rt`/.�i/ /� D 3 _ ,f- �C��- f1 Cj liyCxPJa LotSize/�r►�I.ZI PM 7. //O/f7ii7S } D• /Z/r J Owner's Name Address �- %� 0-1Z-3- - - 2— Phone Contractor s.. f. . l+o.,�'' ..-Address Clicense No. Phvne TYPE OF WELL/PUMP: NEW WELL + WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR d OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ZolAmestic/Private 1:1Gravel Pack LJ Tracy Dia. of Well Casing,, Type of Casing ❑ Public El Other Specifications ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. D��ttepth EI Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump VEIL H p ;Z StateWY ork Done I i Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is \ Installation will serve: Residence— Commercial— Other available within 200 feet.) r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: y SEPTIC TANK ., Water table depth ❑ Type/Mfg Capacity No. Compartments 771 TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line fi 7V�V! ` I LEACHING LINE ❑ No. & Length of lines 4 FILTER BED Total length/size :: ❑ Distance to nearest: Weir Foundation' Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Welt Foundation ' DISPOSAL PONDS ❑ Property Line u 3 hereby certify that I have prepared this application and that the work will be done in accordance with San JOagiuin 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 J employ any person in such manner as to become subject to workman's compensationpermit is issued, I shall not J certifies the following:"I certify that in the performance of the;work for which sperm t is is ued!lI shall emoio Contractor's hiring or sub contracting signature tion laws of California." p y persons subject to workman's compensa- The applicant c or all require inspec' . Complete drawing on reverse side. k 1 g Si ned { Title: _ Date: FOR DEPARTMENT USE ONLY i Application Accepted by CrN Date (]3 Area Pit or Grout Ins 4 pection by Date Final Inspection by I Date Additional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 41835-6385 plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO C RECEIVED-BY DATE PERMIT"NO.'>' +EH 13-241REV. /a to EH 1426 - S Q ` S 3