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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ,l Telephone (209) 466-6781 it PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �I (Complete in Triplicate) i �l 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.-PLq I' Job Address FJ " 1Z so�ke 00 City Lot Size PM _ Owner's Name � �/dL U- ..Ao IA,10. Address Phone �-^ ` r Contractor t` � Address '� � License No. Phone J � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ; SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES RISPOSAt FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OFiWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial+, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing rIl ❑ Domestic/Private ClGravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _-Approxi Depth I 1 Eastern Surface Seal Installed by r �I Repair Work Done ❑ Type of.Pump H.P. ' State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material ISelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.I �� Installation will serve: Residence r' Commercial_ Other Number of living units: A_ Number of b dr oms it Character,of soil to a depth of 3 feet {��¢. Water table depth SEPTIC TANK ❑ r Type/Mf9'_�c�. L Oi?1 1,C!ff —Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal IF Distance to nearest: Well 10 Foundation��__.-_ Property Line _.- LEACHING LINE Prf No. & Length of linesTotal length/size 3 FILTER BED ❑ Distance to nearest: Well Foundation &I — Property Line s� f SEEPAGE PITS I I Depth I Size Number !I : i SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application-and that the work will be do`ne.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 thatin 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'Galifornia:" 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 workm`an's comperisa- tion laws of California." The applicant must call for 411 required inspections. Complete drawing on reverse side. Signed XTitle: —1p1 ;! / Date: r/ t FOR DEPARTMENT USE ONLY Application Accepted by Date � Op,? Area Pit or Grout Ins 'ti i Inspection by Date Final Inspoction by "'~`'`Date Additional Comments: II d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.O. Box 2009, Stk., CA 95201 I INFO AMOUNT DUE + AMOUNT REMITTED 3CCA RECEIVED BY DATE PERMIT N0. /t EH 13-24(R tiNs1 �/ 0— =7 ' = EH 14-26 Z} e+�