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• f APPLICATION FOR PERMIT r ' 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 Distttiict. Job Address / > ID �i I►t 1.QnlZ City + Lot Size a.,tvr� PM Owner's Name �// ��' Address 01!! TD �D1�('AIC��i!- Phone Contractor 4,2u4 zAW — _Address // ense No.��_Phone dJR6'P1Z?j6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER iW 4# d�M'40 .f DISTANCE TO NEAREST: SEPTIC TANK MAN SEWER LINES 4Zd'''' DISPOSAL FLD.�__ PROP. LINE V; FOUNDATION +C2� AGRICULTURE WELL N OTHER WELLASe�. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pace ❑ Tracy Type of Casing Specifications (`i Public 'Other5� l l Delta Depth of Grout Seal +--- Type of Grout I I Irrigation _.Approx. Depth♦♦♦ l I Eastern Surface Seal Installed by •--�+ _ Repair Work Done ❑ Type of PumpH.P. State Work Done Sealing Material (top 50') i) Well Destruction ❑ Well Diameter ! � 2 ` Depth Filler Material iBelow 50) oe TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION i I DESTRUCTION I I lNo 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 r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS 1_1 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 Di1trict. 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 all re a inspections Complete drawing on reverse side. Sign% � Title: Data: of FOR DEPA EN ONLY Application Accepted by pate r 01 Pit or Grout Inspection by Date Final Inspection b Date ^/y Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 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 RECEIVED BY DATE PERMIT NO. ..EH1324 IREV-1/A 5) EH 14-26 S r d