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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA F Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I , (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. Lot Size PM / r �n � Job-Address City 0a, S� Phone`f03- Ysa'z ' G Address Owner's Name p "� R y Contractor ; l 3 Address,006 QC T 6 License Nc,'7 23 "s Phone 33 ` �ZS TYPE OF WELL/PUMP: NEWELL WELL REPLACEMENT ❑ DESTRUCTION El W PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open,Botto ❑ Manteca Dia'. of Well Excavation L'L. Dia. of Well Casing --Domestic/Private Gravel Pack ❑ Tracy Type of Casingr Specifications .jam [1 Public f 1 Other C] Delta Depth of Grout Seal>21 ___ � — Type of Grout -,�� - I Irrigation0--..Approx. Depth l I-Eastern Surface Seal Installed byN��'�--- ` H P 43 _ State Work Done�A/ Repair Work Done ❑ Type of Pump _ _ Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATIOIV`hhEPAIR/ADDITION I I DESTRUCTION l I (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 Character of soil to a depth of 3'feet: Water table depth {' SEPTIC TANK _ 0 Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. Elk k Method of Disposal C Distance to nearest: Well Foundation Property Line ` LEACHING LINE ❑ No. & Length of lines Total lengthisize nn .4 FILTER BED 11Distance to nearest: Well !^ Foundation Property Line Y" I � SEEPAGE PITS f I Depth I Size _ Number t SUMPS ❑ Distance to nearest: Well -_F.oundation-_ ' ProPeftY`Cine' 4� [f DISPOSAL PONDS ❑ '� ` l ' t 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. 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 I 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 subiecto workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. " r" i � �r _ z2- 4'a Signed X.� P .N-�� __ Title: Date: -� k " OR DEPARTMENT USE ONLY Application Accepted by r Date - Area V Pit or Grout Inspection by Date Final inspection by ©al% G 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE "'-PERMIT'NO7— I INFO �-EH t3-24(REV.I/H 5) EH 14-28