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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1E 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 j 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. �,/� Job Address � -3 lam" City 111"[=AL-r- Lot Size PM S I Owner's Namur e22 t �� Address S _ Phone HN ' ,7.2 Contractor Ff� Address .l%C� � License No,J�J 1 Phone 36 63yr33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ s a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ri Public R 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 Sealing Material (top 50') Depth Fillet Material;(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION W4'-DESTRUCTION I I (No septic stem permitted if p y p public sewer is available within 200 feet-) w Installation will serve: Residence Commercial he Number of living units: .2-- Number'of ed aoms` T Q ` r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i,PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: `Well Foundation Property Line LEACHING LINE E"r- No. & Length of lines t Total length/size FILTER BED ❑ Distance to clearest: Well ,Foundation 3 `_,"_ Property Line C� SEEPAGE PITS f'f Depth 2S,{ Size 3(G Number 2 SUMPS E_I Distance to nearest: Well Foundation C) t Property Line �L 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 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 work mans 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." i The applicant must call!,Pr all,required inspections. Complete drawing an ev__arssside. r Signed X Title: _21, dt e-f Date: t e-�r� FOR DEPARTMENT USE ONLY Application Accepted by ' pate "�O� Area Pit or Grout Inspection by� DateJ� �.Final Inspection by ate V Additional-Comments: x i ❑ 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 r CK FEE INFO AMOUNT DUE AMOUNT REMIT-FED CASH RECEIVED BY DATE PERMIVNO. +.EH13-24 MEV.r i n 51 EH 14-2E1