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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT } 1601 E. HAZE I ON AVE., STOCKTON, CA r� Telephone (209) 466-6781 ` 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. a , Job Address -2 4-2 5 I W Q t U�2S City ddCa,ot Size 4 C PM Owner's Name Address 14M Phone Contractor Address_ �� _License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER4❑ } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._—i PROP. LINE FOUNDATION AGRICUL WELL f OTHER WELL ' ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBL REA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottomanteca Dia. of Well Excavation Dia.'of Well Casing . (i) Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications El Public El Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface.Seal Installed by �- \ Repair Work Done ❑ Type of Pump H.P. r' State Work Done Well Destruction ❑ Well Diameter Sealing Material'{top 50') V Depth Filler.Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION'I REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) {� Installation will serve: Residence r! Commercial_ Other Number of living units:t. Number of:beorooms r I f r,,r; r A Character of soil to a depth of 3 feet: .J Water table depth \!} SEPTIC TANK LY Jype/Mfg_ �- ._.. _, Capacity:.-../__. No. Compartments .� OKG. TREATMENT PLT. ❑ _,,,Method of Disposal P ) JJ..i. �7 �rF........-�. _ Distance to nearest: Well ! Foundation i Property Lini7� -"- LEACHING LINE OFflo. & Length of lines `a U. I –�Totatlength/size FILT ED ❑ Distance to nearest: Well ,�r 7 Foundation °�-� t`Property Line SEE PE PI ❑ Depth Size :Numtrer ' { SUMPS ❑ Distance to nearest: Well Foundation I jProperty Line `DISP SAL ON DS ❑ 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. I s"'0 Home owner or licensed agent's signature certifies the following: "I certify that in the perforfnance 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.fif,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 still employ persons subject to workman's compensa- tion laws-of California.."., The applicant mu t c ill f6r all required 'ns tions.,Complete drawing on reverse side. v 4 Signed Title:' f1L>/ en/� y' '• !' 7` �r �� ' F DEPARTMENT USE ONLY I Application Accepted by T Date .r W 1 Are, b Pit or Grout Inspection by Date Final Inspection by' Pate L;rr 17 Additional Comments: r N Qj Stk 466-6781 Q Lodi 369-3621 ❑;Manteca 823-7104 11 Tracy' 835-6305 A Iicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA'95M1 M FEE INFO AMOUNTDUEAMOUNT REMITTED A RECEIVED BY DATE PERMIT'N0. + EH14-24[REV.1/0 57 �1 1 7—EH 1426 V / /?20s' 1