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r` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 46676781 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. ' Job Address r City Lot Size PM 'thOwner's Name U M n/ Address lql ! 6,(/�� 4,y, Phone Contractor Address�7 7`t I r F �1�i�71J License No one / TYPE OF WELL/PUMP: NEW WE WELL REPLACEMENT ❑ DESTRUCTIO PUMP INSTALLATI N O SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FI-D. PROP. LINE FOUNDATION AGRICULTURE WE L OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROB M AREA STRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Manta Dia. of Well Excavation Dia. of Well Casing a ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications k 1-1 Public Cl Other ❑ Del Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I astern -Surface Seal Installed by Repair Work Done ❑ Type of Purr H.P. State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Mater I {top 50'1 Depth Filler Material {B w 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRYADDITION i I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— �mmereial_ Other . Number of living units: Number of �'drooms Character of soil to a depth of 3 feet:'# �� " ' Water table depth ,.�.. r ~_Y SEPTIC TANK ❑ Type/yp g Capacity No. Compartments ( _ PKG. TREATMENT PLT. ❑ Method of Disposal 51 Distance to nn-- Were ,, Foundation Property Line �? LEACHING LINE ❑ Nr, ., girt of lines F y Total length/size FILTER BED ❑r .dnce to nearest: Well >; 1`ounciation Property Line T SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to' nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. 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 parsons subject to workman's compensa- tion laws of California." The applicant u t all f r II required i ctions. Co late drawing on reverse side, n Signed Title: Date: Ill r 1AS FOR DEPARTMENT USE ONLY Application Accepted by Date �� ^L-�� 1G Area Y y —M-'9 Pit or Grout Inspection b Date Final Inspection b Date Additional Comments: � -\:S --1 LA VI � 4 "]6-&-jsI A 'I �--- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environs ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE. 1 AMOUNT REMITTED ASH RECEIVED BY DATE. PERMIT-NO. INFO t.EH 13-24(REV.r H 51 IJ__ I I EH 14-26