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APPLICATION FOR PERMIT ~ ; SAN JOAQUIN LOCAL HEALTH DISTRICT A-� O 1601-E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r,. (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 Joaquln Local Health District. �1 i Job Address �3J 'I �:D.KL��.i i.o City Lot Size- PM- -Owners Name dAd ress /"'"'--t- Phone a I Contractor L -Address IVA 6-t. D - License No..17.2nL_v_Z-Phone TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑` _ r PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ EE�LI I DISTANCETO NEAREST: SEPTIC TANK ' SEWER LINES 01 LD. POOP. LINE-= 4 FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bono" ❑ eco Dia. of,Well Excavation Dia. of Well Casifpf O Domestic/Private - El Gravel Pack- 0 Tracy Type of Casing Specifications I 1"1 Public ❑ O Fl DeltaDepth of Grout Seal Type of Grout_ ,. t I I litigation Approx. Depth I I Eastern Surface Seal Installed by - f Repair Wo ❑ , -Type of Pump _ H.P. State Work Done 1 Well atnrction ❑ Well Diameter _ Sealing Material (top 501 r a ' Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION DESTRUCTION)Q INo septic system permitted if public sewer Is � available within 200 feet.) � r Installation will serve: Residence_ Commercial Other Number of living units: ° Number of bedrooms S Character of soil to a depth,of 3 feet: Water table depth r SEPTIC TANK X�Type/Mfg .Capecitya' No. Compartments PKG. TREATMENT PLT. 171, ' Method of Disposal IDistance to nearest: Well Foundation Property Lina ,y r LEACHING LINE €No. 8 length of lines . �� 3 Total length/size - FIL R BED ❑ Distance to nearest: Well Foundation Property Lime SEEPAGE PITS',, /�I Depth a�i Size Number er SUMPS Ll 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 as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature l 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 a^pplicant/1,,�I1lust call (E9 all ad inspection. Complete drawing°(�,'�{aver�e s/^iide..I Tide: ; /ter✓ —/ Date: FOR DEPARTMENT USE ONLY Application Accepted by _ ^ `w '�' `^r"" Date 1\,��1��_ 1.:_ Area __. _ Pit or Grout Inspection bye Date Final Inapecgon by. A`�'"y/ - Dau T Y \ . p ' Additional'Camments: ❑ Stk '46&6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 J� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, SM., CA 85201 1 FNFEEO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED 13Y DATE PERMIT'NO. /q .t . EH 13-34 IREV.vs,FI �O ) FN 14,1 1 .. __.. _