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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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. c Job Address373 Y JUPAJ40, City `''� Lot Size PM Owner's Name + r _( ■ y Srti'V(11&_ dress 4%62,Petal j� /�WIG iv0 Phone Contractor Cit!`M(W- Address bl r+ .Cili/If t ^ License No.3 11�Phone a �� V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ;P-'� 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 i❑ lndu ial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Zmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other Ll Delta _ Depth of Grout Seal Type of Grout I I Irrigation IA ---Approx. Dept ( I aste ace Seal Installed by • _ Repair Work Done Q--"Type of Pump H.P. State Work Done MCA , Well Destruction ❑ -Well Diameter Sealing Material (tap 501 . Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is V. . r �,, available.within 200 feet.) Installation will serve: Residence_ .Commercial_ Other ' �^ Number of living units: Numberofbedrooms I W Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHIIVGI'LINE } �❑ No. & Length of lines Total length/size FILTER BED ❑ Distance.0to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ti 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 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 to ome subject to workman's compensation laws of California."Contractors hiring or sub contracting signature certifies the follo)Glt "I certify t tin the ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of Cali The applican all fo all r re ins ion . mpl to drawing on r vers Signed XI Title: Date: FOR DEPARTMENT USE ONLY Application Accepted b_y_ -- _-.... . ,Date. _. Afea k -Pit or Grout Inspection by Date_ - Final Inspection b �) Date`s �? Ad ditional Comments: �.� Stk 466-6781 ❑ Lodi,369-3621, ` ' :O Manteca"823 7104 EI-Trac—y" 835-6385 w A plicant - Return allcopies to: Environmental-He:31th Permit/Services.1601,E. Hazelton Ave., P.O.,Box 2009, Stk., CA 95201, -. Y INFO FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH t3-24{REV.i/n 51 `--�^ �~ q as -7 1 A,�,/ 3s� EH 14-28 �d