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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 f (Complete in Triplicate) ' Application is hereby made to the San Joaquin Local Health District fora 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 Phone Address / � � Owner's Name �� -� Contractor I` # Address_�tgt l�Q /YET License No Phone TYPf OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ RR 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing C1 Domestic/Private LIGravel Packi ,, AD_Tracy^ __-,_.._.., , ype of Casing Specifications 1-1 Public E1 Other s L] Delta Depth of Grout Seal Type of Grout I 1 Irrigation --Approx. Depth I I 'Eastern - Surface Seal Installed by Repair Work Done ❑ Type of Pump' { H,P. ' _` __ State Work Done Well De¢truction ❑ Well Diameter, Sealing Material (top 501 F Depth Filler Material lBelow 50') -0. TYPE OF SEPTIC WORK: NEW INSTALLATION I I -REPAIR/ADDITIONX DESTRUCTION I.1 +iNo septic system.permitted if public sewer is (yam ..i available within.200 feet.l �J A Installation Will serve: Residence Commercial•�s, Other _� Number of living units: Numb; rOof bedrooms y •R ,„ ,tM � � .�_ - Character of soil to.a depth of 3 feet:# E .S*4,Ai-b e►1�, Water table,depth SEPTICTANK i ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ -. ' Method of Disposal Foundation Property-Line I i Distance to nearest: Well I LEACHING LINE No. &'Length of lines .:* y Total length/size. FILTER,HED t ❑ Distance t`oS rnearest: Well Foundation Property Line SEEPAGE PITS "I"1''Depth a «„ f"Size ; Number SUMPS Ll Distance to nearest: „ Well^moi' .� ` ," Foundation Property Line DISPOSAL PONDS; ❑ ;Z r;`.i l y� ' '� �~ I hereby certify that 1 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. 11 .` .-Nome 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 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 laves of California.'' l �, The applicant must call for a X all equired inspections. Gornptate drawing on reverse side. S /./f�j Signedl �6 � - - -� j, `f ,Title; � nate: p FO DEPARTMEr4f USE yONLY r� �7t A lica+tion Accepted by ' Date ¢— v Area PP Pit or�G rout Inspection by ,Date Final Inspection by Date Additional Comments: . O Stk{ 466-6781 ! ❑ Lodi 369-3621 Cl Manteca 823-7104 " ❑ Tracy 635-6385 Applicant - Return all copies to.: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,%,Stk., CA 95201 _. FEE- i_ __..�.. CIC _ INFO AMOUNT FUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EH13-241REV.I/H51 _ .l - +- _" _._ .-..-%-•. - �st �U EH 14-26 <2l