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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. a . v rf Sc� iQ L, � -. CI .®wiE��i r �5 s Job Address � City Lot Size PM Owner's Name �+ "lam O ' Address -547' Phone A. Contractor r /' L G=AR Address jR 6:� License No. �ffy`= Phone TYPE OF WELL/,PUMP:-,�j" NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ /'1�-PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO,NE'AREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' r`.,z X 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 ❑.Public ❑ Other ❑ Delta Depth of Grout Seal r Type of Grout Z/ ❑ Irrigation ---Approx. Depth 17 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H`P. State Work Done Well Destruction ❑ Well Diameter `Sealing:Material'ftop 50'1 �t Depth ;Filler Material (Below 50') ` •cam TYPE OF SEPTIC WORK: NEW INSTALLATION ❑r-REPAIR/-A-DDITION DESTRUCTION ❑ Wo septic system permitted if public sewer is J�3 ;qy ,. :x'171 i available within 200 feet.i Installation will serve: Residence��Commercial Other: Number of living units:.i M. Number of bedrooms �-b j Character of soifsto a-depth-:of 3 feet: «--, J�..S + ►g'"� ^'� Water table depth SEPTIC TANK ❑ Type/Mfg %Capacity No. Compartments PKG. TREATMENT PLT-'.'[-]' b r Method of Disposal Distance to nearest: Well Foundation ' Property Line LEACHING LINE I No. & Length of fines Total length/size" ~ FILTER BED /❑ Distance to nearest: Well 9.'S Foundation�/�' � Property Line / w SEEPAGE PITS O Depth j` Size f Number e i SUMPS, ❑ Distance to nearest: Well Foundation € Property Line 4 DISPOSAL PONDS ❑ v 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 L9,cal HealtF District. Home owner or licensed agent's signature certifies the following: "I certify that in the pefformance 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 y. 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 911 requiro ins ctions. Complete drawing on reverse side. { Signed X ' , Title: Date: FOR .DEPARTMENT USE ONLY z Date r Area—06 Ofd Application Accepted by Q Pit or'Grout Inspection by Date Final Inspection by ' Date s [ r Additional Comments: p e j ❑ 5tk 466-6781 ❑ Lodi 369-3621 I C] Manteca 823-7104 ❑ Tracy 835 f385 C(�y15�C�j�7 Q �D�r� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. HazeltonAve,,P.O.'Box Stk., CA 01 ^ � �FEE�,_,,,.,,,AMOUNT.DUE ----AMOUNT-REMITTEDt— 7 CK " "-AECEIVEO"BY"` "DATE -' PERMIT N0. INFO CASH 13-24 1REV.i EH 14-26