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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L't (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 "`Lat Size gD PM LD Job Address _ fi. Cj �ddress A61�1.� �.�L �/N� Phone 7� o Owner's Name _ _ i L Phone Contractor's Name S -3icense No. TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT 13 DESTRUCTION 11N PUMP INSTALLATION F] SYSTEM REPAIR L3 OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE !- FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS s ' INTENDED USE TYPE-OF WELL - _PROBLEM.AREA.,r.CONSTRUCTIOIV`SRECIFICA710NS, Dia. of Well Casing Q Industrial jy/ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ._ D Domestic/Private1 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Y j i%lb Irrigation ' =.�pprox. Depth ❑ Eastern Surface Seal Installed by i :�Repair Work Done'❑ Type of Pump * H P• State Work Done Se Material (to 50'1 ' Well Destruction ❑ Well Diameter g p -}� Depth Filler Material {Below 501 , 4 i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted•if public sewer is tavailable within 200 feet.) S fes' ,,Installation will-serve: Residence x Commercial_ Other Number of living units - Number of bedrooms _ } Character of soil to a depth of 3 feet: '""*H Water table depth - �: Capacity/_ - No. Compartments SEPTIC TANfC` a Type/Mfg /➢[aE PKG. TREATMENT PLT. ❑ r ,. '`"„""�"'i / Method of Disposal ' C F r 1f r'S ' l0 Property Line4r' � Distance to nearest: Well�� Foundation LEACHING LINE No. & Length-of-lines }� J ` Tatallength/size 1 I FILTER BED ❑ Distance to nearest: Well I t' I 49 Foundation. _ Prope Y Line, ; t ��/ -Numberr� SEEPAGE PITS Depth = i SUMPS (❑ Distance to-nearest: . Well Y Foundation /V� Property Line DISPOSAL PONDS ❑ � 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 Sari-Joaquin Local Health District. T 1 Home owner or licensed agent's signature certifies.the following: "I certify that in the performance of the work for which this-permit-4s i sued, I shall not employ any person in ch manner as to become subject to-workman's compensation laws of-Caf'ifornia:”Co_r t1Facf6_e9 lilting or sub-contracting.signature ` certifies the followin "I certify that in the perfor ance of the work for which this permit is issued,I shall employ'i rsons subject to workman's compensa- tion laws of Califor The applicant s for all re fired ins ons. Complete drawing rev } date: Ly— Signed Title: t .�!� j a FOR DEPARTMENT USE ONLY ` • t L. Application IL Area Application Accepted-by ' Date F I r 1 7 Pit or Grout Inspection by Date Final Inspection by Date Lf r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621]1 IN ❑ Manteca' 823-7104 EI Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 r FEE .AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. �7 + EH 13-24(REV.10163E _ d o _ "'�l \ `-' -_7 EH 14-25