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APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)n�8 4.1 3y,� PERMIT EXPIRES 1 YEAR 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- ' X Job Address Q1 166 IC2�s_(v 1X114n- &CityXV49 Lot Size PM kOwner's Name t Kd"�► AY'� J?2_1 Address Phone 9yr�a�j XContractor; L✓A h - d Address !.707a?)m a License No. Phone // 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 �Q ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -- i I Irrigation _,-Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l.1 DESTRUCTION t I Wo septic system permitted it public sewer is (ti avaiiable within 200 f t.1 "\ Installation will serve: Residence A Commercial_ Other f d C„ pix��eN q Number of living units: Number of bedrooms 1 CJ Water table depth f Character of soil to a depth of 3 feet: p SEPTIC TANK �[ Type/Mfg' J C Capacity �>�� No. Compartments PKG. TRFfATMENT PLT. ❑ ' r r Method of Disposal ! Distance to nearest: Well Foundation Property Line r ` . LEACHINI�fLINE�-'� J< No. & Length of lines d— Total length/size Da FILTER BED f f ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 -Depth Size Number SUMPS Cl Distance tb nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I 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 applicant mus all r all requirgo inspectto s. Complete drawing on reverse side. Signed X Title: - _ _ � -Date: 3 r R DEPARTMENT USE ONLY Application Accepted by �� , Date �^ Area ` Pit or Grout Inspection by Date Final Inspection by C/"�Date Additional Comments: j?K OK /// El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tr cy 635-5385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO MOUNT DUE AMOUNT REMITTED I C K RECEIVED BY DATEQ' PERMIT'NO. .. ii EH 13-24(REV.r/A 51 EH 14-28