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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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, 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �f J 7� ` y'�J 1 `.' _,1 � /v -u Cit �' G C Lot Size PM Job Address ,- - ,yam y Owner's Name a- ofOyldel Address Phone Contractor _ 4r,"Il G l' Address Pa6oir 1 License No.:7 b_ Phone 35 —tl2S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP°INSTALLATION'❑ '" 'SYSTEM REPAIR ❑ 'OTHER ❑• — DISTANCE TO NEAREST: SEPTIiC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing s ❑ Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing Specifications F Public +' ❑ Other ❑ Delta _ ___ Depth of Grout Seal a W x Type of Grout ., } I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. ` State Work Done_ E Well Destruction ! ❑ Well Diameter Sealing Material (top 50') Depth Filler Material I Below 50'i t TYPE OF SEPTIC'WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is '" --• —available within'200 feet.l' ^�/ „' ( v - Installation will serve: Residence_ Commercial 3 Other- 4 f Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: 0 a Water table depth SEPTIC TANK Type/Mfg G rPi�� Capacity0_ncm -- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disppsal ' Distance to nearest: Well Foundation 46� -::-'.Property.Line 3� c LEACHING LINE No. & Length of lines T Total length/size Q ` s FILTER BED E3 Distance to nearest: Well �' Foundation _- Property Line SEEPAGE PITS C I Depth Size "" Number 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 Diltrict. ' 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 sub-contracting signature i. 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." + yr <<a The applicant must call fo all require ns tions. Complete drawing on reverse side. � Signed X Title: i `�� Date: FO D ARTMENT USE ONLY 3 Application Accepted by Data 2 Area_/v Pit or Grout Inspection by Date Final Inspection by Date I { I Additional Comments: s ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 t ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave_ P.O. Box 2009, Stk., CA 95201 ` (� e FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH Q ♦.EHt3-24(REV.r/n5) EH 14.26 ( 1