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.� w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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.-- p Job Address 1 3c�oobAl City Lot Size - , PM Owner's Name Address Phonez a ` —C?a 4/ Contractor /! Q-!w— d'�- Address License No.Z/ *-ISPhone r - �/2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP 1NSTALLATIONX SYSTEM REPAIR ❑ OTHER ❑ v DISTANCE TO NEAREST: SEPTIC TANK Zoa SEWER LINES DISPOSAL FLD. PROP. LINE a FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF KNELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,ye ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing a Specifications M Public rl_1 Other 171Delta Depth of Grout Seal `O_ A__ Type of Groutl�_E�_. I I irrigation 'L4Y&•.ApproxADepth l I Eastern S�rface Seal installed by A t _ Repair Work Done ❑ Type of•Pump Sf H,P. s' State Work Doe Well Destruction ❑ Well Diame ey Sealing Material (top 50') Depth Filler Material (Below 501 -` d TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION l I (Ne septic system permitted if public sewer is a -"- ---` a"ilable within 200 feet.) Installation will serve;: Residence_ Commer:cia[ Other Number of living units: Number of bedrooms ' t Character of soil to a depth of 3"feet: Water table depth a t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No`&•Length offlie- r Total length/size r FILTER BED ❑ Distance to nearest: Well Fou dation Property Line ; p f ` SEEPAGE PITS l I Depth Size Number e SUMPS - ^"�L'l�""Distance t`o nearest: WeII—Fo6 d5-ti6n_— Property Line DISPOSAL PONDS ❑ ttik. _ t, 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 ce4ify 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,I shall employ persons subject to workman's compensa- tion laws of California." f r ^The applicant must call for all required inspections. Complete drawing on reverse side, Signed X ..•-_-- m Title: Date: ,FOR DEPARTMENT USE ONLY /J� G i Application Accepted by /\y Date v ( Area '�� Pit or Grout Inspection by / Date j r� Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazolton Ave., P.O. Box 2009, Stk., CA 95201 INFO "AMDI)Nf DUE AMOUNT.REMITTED+ RECEIVED 4Y DATE DATE^'^ 1}ERMIT'AO;'" i E,13.24(REV"iiH5 0 .. EH'14-26