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APPLICATION FOR PERMIT $ i�"' '`�� y.^ Ew � i SAN JOAQUIN LOCAL HEALTH DISTRICT T-� 1601 E.�HAZEITON AVE., STQCKTON, CA Telephone(209) 466-6781 0 l ;tai n '1gA7 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) T:N1tlR0k_1 .1 i R HEATH i ��f�JIt1��5ER1/ICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work In e ri e c-ri ed. 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. a Job Address a , kcA— City S. PM Owner's Name I[7 to it A CC . Address LPhone J_� { — �d/ j"_ / Contractor ess___P0 License No.��-!7 x,L Phone t7 TYPE OF WELL/PUMP: NEW W LL ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation � -Approx. Depth I I Eastern rface Seal'Installed by - Repair Work Done L4e Type of Pump � � f- .H-P. State Work Done Well Destruction ❑ Well Diameter r I Sealing Material itop 50') Depth Filler Material (Below 50;1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is 1 { available within 200 feet.). ---Onstallatior-will.serve: .Residence_ Commercial Number of living"units: s Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT, ❑ Method_of Disposal Distance to nearest: Well rY Foundation Property Line ;„;,(„LEACHING LINE, ❑ No. & Length of lines Total length/size k FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 o he San Joaquin Local Health District. Home owner or " nE d ag is signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not employ any rson in such m nner as to become subject to rkman's compensation laws of California."Contractors hiring or sub-contracting signature certifies t following: "l ce y that in the rmance h' ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion law of California." Thea lica& al or all r rr plate yawing on e I Signe X itle: Date: ` AF/ FO EPARTMENT USE ONLY Q� Application Accepted by Date r.`'� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: T7 ❑ Stk 466-6781 ❑ 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, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE �PEER_MIT'NO. ♦ EH14-24 IREV.,/x 51 r3�- EH 14-26