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r� r—IN APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON 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.f l i 6'T 5o S 4_ � ,Zjenc:e. KZ) -- Ci E5CL?6n Lot Size PM Job Address _ tY (� �� ' _ i Owner's Name '�h _ Address Phone2-`? Contractor's Name 6SfyS�� - License No. 20 4Phone S� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 0.Manteca Dia. of Well Excavation Dia. of Well Casing S f ❑ Domestic/Private ❑ Gravel Pack -(❑ Trac Type of Casing Specifications V) � 4 El Public El Other El-Del a". Depth of Grout Seal Type of Grout ❑ Irrigation __- Approx:'Depth ❑ Eastern . Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 4 State Work Done Well Destruction ElWell Diameters Sealing Material Itop 501 Depth Eller Material 1Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is available within 200 feet.) F Installation will serve: Residence_X_ Commercial_ Others Number of living units: __�— Number of bedrooms _ Character of soil to a depth of 3 feet: -� Water table depth 2C r SEPTIC TANK E?- Type/Mfg fa i'1Yl(_, Pte.�'as`7� Capacity da No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE [ No. & Length of lines +n'-• Total length/size 0 FILTER BED ❑ Distance to nearest: Well 17 Foundation S Property Line,/_3p SEEPAGE PITS ❑ Depth 'z —Size c2 X 1 Z bC rs Number SUMPS Distance to nearest: Well I r!ra _ Foundation ISS . Property Line �9-D DISPOSAL PONDS ❑ 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."Contractors hiring or sub-contracting signature certifies the fallowing:"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 m st call for all requir ns c ns. Complete drawing on reverse side. Sign ad Title: Date: ZFOR DEPARTMENT USE ONApplication Accepted by res +� ,�9 0 --- Date U L `13 A Area / Pit or Grout Inspection by Date g'lg-g4 Final Inspection by r' -- c 1 Q•�,be-Date Additional Comments: ` ❑ Stk 466-6761 ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO CASH , + EH 13-24(REV.101831 S oa 1141 EH W26 - - ,.✓