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. t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. t Job Address �� i� ✓" "� Cit /5 Q r� p Y Lot Size " PM �¢ Owner's Nam yB L( U !$8 7ITl��l �G� ��K � � —i -- I �4 _ Address Phone Contractar e 15e Address License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private El Gravel Pack Dia.uof Well Casing ❑ Tracy Type of Casing4 +n 1 M Public ,speo15 Delta Depth of Grout Seal '. i I I Irrigation [� Other F1 �' --.Approx. TYPe cifications of Grout I depth I ] Eastern Surface Seal Installed by ;� Repair Work Done ❑ Type of Pump H p - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler-Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 AEPAiA/ADDITION l 1 DESTRUCTION (No septic system permitted if public sewer is r Installation will serve: Residence Commercial available within 200 feet.) Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet:. a SEPTIC TANK ❑ T I Water table depth , Type/Mfg MCapacity No. Compartments PKG. TREATMENT PLT. Cl Meihod of Disposal \�M" Distance to nearest: Well Foundation \� .Property Line � .� .- LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to.nearest: Well Foundation i L' �r. Property Line r SEEPAGE PITS I I DepthSize C SUMPS to Number I Cl Distance nearest: Well Foundation ' DISPOSAL PONDS ❑ Property Line I j I hereby certify that I have prepared this-Zplication 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 DFstrict. 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-cbritracting signature r certifies the following: "1 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." . t, The applic must call for all `r ired ' Pe ions. Complete drawing on reverse side.. Signed X V`' _ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by y Date Area Pit or Grout Inspection by Date Final Inspection by Date9 Additional Comments:, n ❑ Stk 466-6781 ❑ Lodi 369-36271 q 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE _ PERMIT NO. +.EH 13-241AEV.Fie5l //jl�i EH 14-28 U ��fS V