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tr✓ 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) 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. r19 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,�/ Job AddressC7�Lti1// e6� City/ Lot Size PM Owner's Name Qats a6r—j" A44�. . Address��yd Phone Contracto - AddressjI!?421*A 114uw_Z_-�195, 1_icense No.JA9&_6__ - Phon TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �jjPUMP INSTALLATION X SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEARER: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , '�Indusirial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _._. I I Irrigation _.Approx. Depth I I Eastern , Surface Seal Installed by "-►- _ Repair Work Done ❑ Type of Pump,4" H.P. A` State Work Don 5��( Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms 09 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK .❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: {/Nell Foundation Property Line LEACHING LINE Cl No. d Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued„1 shall employ persons subject to workman's compensa- tion laws of California.” The applicant ( r all required i pectipnS. Complete drawing on reverse side. p Signed Title: Pit" Data: ,(OAR DEPARTMENT USE ONLY �f Application Accepted by �/'�/`� Date / / �� Area �+ / Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Sik 466-6781 O Lodi 3619-3621 ❑ 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 FEEK INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMITNO. r EH1124(REV.it x b, es EH 14.M n I I D u C 11 E