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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA NO Telephonle (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED �t0� L ` E Womplete in Triplicate) c,4 /A`?-, 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 6r No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. Job AddressQ�� [' /Y Cit of Size �,��/ PM —.� /�� I y _"V rte`r K_- — t Owner's Name_-`_l �Cf2�/�CO �lUJ7�l-Z Address Phone Contractor S, t Address License -No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ 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 vv ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other 8! ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approxi Depth i I Eastern Surface Seal Installed by f Repair Work Don ❑ Type of Pump H.P- State Work Done Well Destruction ! ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 l ' TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION l I DESTRUCTION' (No Septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence Commerciei Other Number of living units:is Number of bedrooms Character of soil to a depth of 3 feet "" IlVater table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Dispose! Distance to nearest: Well Foundation Property Line t� n LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line t- SEEPAGE PITS I I Depth Size Number .—SUMPS ' ❑ Distance#to nearest: Well Foundation Property Line .-.....DISP.04L`PONDS E1, _ ,.i �_- __ _• w �,� �-�— ^� ,�_�. - _. 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 fo become subject'to workman's 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 ofCjlifornia." £ ` The applicant' lust call for alt required inspections. mplete drawing on reverse side. Signed X LLL Title: Date: R D NT-USE ONLY f Application Accepted by Date "7 V�!� Area `� Pit or Grout Inspection by �J Date Final Inspection by � 2`Cs>:� Date J Additional Comments: / ' - 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health.Perriit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'Nb. �..EH13-21(REV,tins) EH 11-26