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APPLICATION FOR PERMIT - .x 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 heieby 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 '[j 000,/21,4-?t=t_S City C - Lot Size_ ' 'r PM r Owner's Name S /L u Address o c� ��l/J�9/H 4FW--S Phone Contractor._ .� i""1�� G Address � � ,T.+ License fV Phone TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE t „ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS U,1 .1NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _, Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications" M Public ❑ Other n Delta Depth of Grout Seal Type of Grout .. t 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 0 Well Diameter - Sealing Material {top 501 j x Depth Filler Material (Below 501 TYPE OF"SEPTIC.WORK:.`.,-NEW INSTALLATION ?C REPAIR/ADDITION t l DESTRUCTION t I (No septic Vystem permitted if public sewer is s �' / available within 200 feet.) Installation will serve: Residence, Commercial_ Other . Number of living units:: 3� Number of bedrooms _ - r Character of soil-to a Aepth of 3 feet: r 1 _ Water•tabie depth r s SEPTIC TANK Type/Mfg Capacityt' , p PKG. TREATMENT PLT. ❑ "`""'_ c',�a, 4.�F- - �' Methodof Disposal Distance to nearest: "Well Fo dation !a \Property Line-- LEACHING ine4LEACHING LINE TJX No. & LengWof lines T 1. Total length/size T i FILTER BED rt-" ©;j Distance to nearest:- Well aFoundation �� Property Line SEEPAGE PITS I I Depth Size. _=Number_ SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �' ' 4". ` 1 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 II require4 inspections. Complete drawing on reverse side.. ; t �y /y Signed X Title: Date: FOR DEPARTMENT USE ONLY. Application Accepted by _ 61 - Date 7 2 oP� Area ; I } Pit or Grout Inspection by Date Final Inspection by Date2—_.27-?oa7—?7 r r 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, Silk., CA 95201FEE y INFO AMOUNT DUE AMOUNT REM17i CASH RECEIVED BY, DATE PERMIT NO. t-EH 13-24(REV.tike/ .7a --- f EH 14-26 t i