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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 1 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 Joaquin Local Health District. Job Address / City Lot Size PM J 4 y Owner's Name Address / / Phone "Contractor , Address—v� - - � jcense',No..ly13.�.+4tf?hone_ V� z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SE ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI ULTURE WE OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AR C STRUCTEON SPECIFICATIONS ❑ Industrial El Open Bottom y._❑ Manteca ia..of.Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i-I Public ❑ Other t Cl Delta Depth of Grout Seal Type of Grout _ €€ 1 l Irrigation,- Approx. Depth f I Eas rn urface Seal Installed by Repair Work Done {J Type of Pump I �wH;P._�r State Work Done_ Well Destruction ,. ❑ ';Well Diameter;' Sealing Material (top 501 Depth I Filler Material (Bel w 50'1 " TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I I INo"septic system permitted it public sewer is + ' available within 200 Leell 'r Installation will serve: Residence Commercial_ Other� ,0, PV Number of living units: Number of bedrooms f�? Character of soil to a depth of 3 feet: ! f? 1 t Water table depth SEPTIC TANK ❑ Type/Mfg dL pacity No. Compartments # PKG. TREATMENT PLT. El �o., Method of Disposal Distance to nearest: Well' ` .Foundation Property.Line ot LEACHING LINE ❑ No.,&Length of lines ' Notal length/size FILTER BED ❑ Distance to.nearest: t�Well ,Fou n ation Property Line SEEPAGE PITS I I Depth w� §iJM kZ� Number SUMPS Ll Distance to nearest: a Foundation Property Line` DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done An 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 E employ any person in such manner as to 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 of California." The applica ust Galt far a required i specttons. Complete drawing on reverse side. ^4 Signed X Title: CA=ec J"'Y�J9/1 Data: " tt "•�,,, F, DEPARTMENT U5E ONLY { r"F --". Application Accepted by _ Date �� Area r "- E Pit or Grout Inspection by Date Final Inspection by �fiYO� Date Additional Comments: w ❑ Stk 466-6781., - ❑ Lodi 369-3621 ❑ 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 t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. k INFO CA H- ---�- ,,.,..�. .rte- .-.r�.....- - —— _. ... �' - - + ♦.EH 13-24 IREV.i/n s, fit G'0 1'~1 '3Q 'F. EH 14-28 "''"�� V 1