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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 IE. 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 I 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 ce-oYiU S r(DI �6• City SA_04 k rt' Lot Size PM Owner's Name Qt ! Address IZZI E• h?stin Sk &L&44,yr a rx/ / Phone Contractor I r CaY POr"JI11 M Address 4'91J Avpt&J' W4lrh*Ie- /j 21 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ 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 ++ j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Do estic/Private K Gravel Pack ❑ Tracy Type of Casing aV Specifications; .)c pwak/0Or,%A_`t/ Other E Delta Depth of Grout Seal Type of Grout! ❑ Irrigation VXW4( YdV4��gpprox. Crepth ❑ Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ,Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: %Number of bedrooms o ms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - Method`of Disposal Distance to nearest: y Foundation--- ._ Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Vile Foundation. Property Line SEEPAGE PITS ❑ Depth ize Number SUMPS ❑ 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 District. y� 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, 1 shall not employ any person in such manner as to become subject to workman's compensation this permit is issued, I shall employ persons subject to workman's compensa- compensation laws of California."Contractor's hiring or sub-contracting sign Califsignature 1 certifies the following: "I certify that in the performance of the work for ' tion laws of California." The applicantm II for all required ins ns. to drawing on reverse side. Signed X_. _ -- Title: .. / - _ Date: F R D A NT USE ONLY Application Accepted by _ _- Date- _." _ Ar a Pit or Grout Inspe (on Date 3—_2-<---_& Final Inspection by �._ Date Additional Comme t❑ Stk 466-6781 Lt Lodi 369-3621 ❑ Marrteca 823-7104 :i Tracy 6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED REMITTED_ RECEIVED BY DATE"J PERMIT NO).INFO CASH 00 EH 13-24(FEV dr 31, T EH 1426 -