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APPLICATION FOR PERMIT 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 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM 01 Owner's Name Address "► / Phone 9 g Contractor.J�_ Address License No.d 0 ,tel PhonA.7 � 3 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 r 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 I'1 Public ❑-Other n Delta Depth of Grout Seal Type of Grout--- I rout _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 ❑ Well Diameter Sealing Material (top 50') r Depth Filler Material !Below 501 `i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 1No septic system permitted if public sewer is w a�_ available within 200 feet-1 Installation will serve: Residence. Commercial--.0 her Number of living unitsNumber of BroomsCharacter of of soil to a depth of 3yfeet: Water table depth--'a SEPTIC TANK LtY Type/Mfg Y6 Y if Capacity lobb - No.'Compartments 2- PKG. PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well t ,Foundation Property Line Q t LEACHING LINENo. & Length of lines 4 'Total length/size 1 I FILTER BED N ❑ DistInce to nearest: Well 3s I Foundation �'` (., Property Line 10-0 t SEEPAGE PITS IH-,Depyh Of ( Size �� If Nrumber SUMPS Cl Distance to nearest: Well.lt ., ''-Foundation 0 Property Line f DISPOSAL PONDS r ❑ 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. 'rr f I \ �>a 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 n+ tk.: employ any person in such manner as to become subject to workman's compe6satioii 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." 1l The applican ust call for all r quire inspections. Complete drawing on reverse side. y SignedX -Title:a L(�lL�C -,2��F6 i I Date: FOR DEPART ENT USE ONLY i Application Accepted by Tate Area I f b or Grout Inspection by Date i knal Inspection by ate �' i Additional Comments: l ❑ Stk 466-6781._.•,a. ❑ Lodi 369-3621. ❑ Manteca 623-7104 ❑ Tracy 835-6385 .� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,-P.O.,Box 2009, Stk., CA 95201 r FEE INFO MOUNT DUE AMOIJ/NTlREMITTED -* H RECEIVED BY DATE PERMIT'NO. +. 4-24{REV.r i 5Y EM 14 H 7 EH 28 DU 7 UX