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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 (Complete in Triplicate) r 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. Job Address U ydF �(Os4eT ��' City�na�L r Lot Size ��S-- PM t 0 �s3co-ta2to l(0 LL, s ! Owner's Name +�C Y1Q _ Addresses Phone O" G ' ' y Contractor [' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C3PU P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST'ZEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED LJSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial l ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic//Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'1 Puhtic ❑ Other F1 Delta Depth of Grout Seal Type of Grout—.- 11 rout11 Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ fdepair Work Done ❑ Type of Pump H.P. State Work Done /Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence N)<- Commercial— Other Number of living units: A_. Number of bedrooms _ .�.. ,w�■wr... Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments. PKG. TREATMENT PLT, ❑ f Method of Disposal Distance to nearest: Well G1 Foundation I C-o Property Line 1 1 LEACHING LINE DIC, No. & Length of lines '" Total length/size tZ FILTER BED ❑ Distance to nearest: Well 9; �4� Foundation Property Line SEEPAGE PITS l I Depth (��- Size Number �.. 7- ;I SUMPS A Distance to nearest: Well Foundation Property Line, DISPOSAL PONDS Cl E �� I 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,,and rules and regulations of the San Joaquin Local Health District, 1 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 required inspections. Complete drawing on reverse side. t Signed X dlQ J I.Z � a N�4lr_20 io� Title:�� _ - -_ __ Date: 7-,23-22 f _ FOR DEPARTMENT USE ONLY y.r ��7] Application Accepted by Date Area / ' Pit or Grout Inspection by Date Final Inspection by �-S Date Additional Comments: ^ + r l kStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 e 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 GASH CK RECEIVED BY DATE PERMIT NO. i EH 13.24(REV.tins) EH 14-26 [ 6Y o