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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. FahoN Z5ZA- 1�.` Job Address _Tu I Ig ky"y'V6 _ City Lot Size ,4t PM Owner's Name 4lt IQ C0 BV i�✓ �Addess r Address Phone Contractor AC� .Az rr�fv License No,- -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ t SYSTEM REPAIR ❑- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLI]. PROP. LINE a FOUNDATION p AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack i_] Tracy Type of Casing Specifications I'1 Public i_1 Other F1 Delta Depth of Grout Seal 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 _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted'if public sewer is f available within 200 feet.) Installation will serve: Residence-Z Commercial_ Other Number of living units: Number of bedrooms Character of soil to a dep h of 3 feet: 003e Water table depth SEPTIC TANK t( Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ¢ s C� - -Method of Dispoaal Distance to nearest: Well -�G Foundation _-..- Property Line 7 4Z LEACHING LINE 1 {. No. & Length of lines Total length/size FILTER BED r❑v distance to nearest;, _ WeJI. 60 t Foundation Property Line f SEEPAGE PITS l I Depth r Size 6!�1' 5f COQ Number SUMPS Distance to nearest: WellA4"Pa Foundation _Property Line— 7Y 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. 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 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." The applicant must call for to ired inspections. Complete drawing on reverse side. Signed XTitle: Date: FOR.DEPARTMENT USE ONLY Application Accepted by 6) Date A Area -2-116 Pit or Grout Inspection by Date Final Inspection by ate /c Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 f FEE 06+ INFO AMOUNT DUE AMOUNT REMITTED CASH RE=CEIVED BY HATE PERMIT Nd. + EH 13-24(REV. /a hl "�" EH 14-2e _ - <