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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E, HAZELTON 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 Joaquintounty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.. �] '(�►[��-.1 Job Address 5 ! r`rLM_A_n� - - City ` Lot Size PM Owner's Names✓ Address Phone 3(09 1c 0 IL3 l mC ol Phane�,�7 U—S j v 5 Contracts .pddress l e License Na. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f` 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 t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications k ❑ Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation' --Approx. Depth I I Eastern- Suiiace Seal installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 501 Depth ler Material (Below`50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 Rl i'AIR ADDITION I DESTRUCTION I I INo septic system permitted if public sewer-is t " � available within 200 feet.) Installation will serve: Residence Y.+`Commercial— Other / {, Number of living units: .._.L-.-. Number,of J rooms i a(as, - r r Character of soil to a depth o(3 feet: �` �' '' �' Water table depth ( - SEPTIC TANK ❑ Type/Mfg `j * CapacityNo. Compartments ((� PKG. TREATMENT PLT. Eli �' Method of Disposal Distance to nearest: '"`1iV611— Foundation ` Property.Line ` LEACHING LINE No. & Length of lines Total length/size-1-6-1,11 FILTER BED ❑ Distance to nearest: WellS� Foundation �� f Pro erty Line J f t 7 .t. .1�.r r SEEPAGE PITS f l Depth'1 ^SizeY. ~ y.I m p2 � 16 Nuber J r o �_ SUMPS Distance to nearest: Well inn Foundation Property Line DISPOSAL PONDS ❑ T.-�.�, � � i 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, an I 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." f !i The applicant must all for all r uire inspections. Complete-drawing-on reverse side. i Signed X Title: V 3 Date: __- FOR DEPARTMENT USE ONLY ' AppiicationAcceptecThy' - j - Date ? Area i / I rtZo'f1U_Ct_,71rm'me�ttV0s,: _ speyr ate �- Final Inspection by•-Ad ❑ Stk 466-6781 0 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 95201FEE n� INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED SY DATE PERMIT NO. +.EH 13-24(REV.t 111.51 EH 14-26 //�/ 'En 7119