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APPLICATION FOR PERMIT F' SAN JOAQUIN LOCAL HEALTH DISTRICT r 1691 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit tb 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 it, Lot Size PM Owner's Name/'&Vc#*A,Nl 06dclress ! i 77 6(t 69 1'6�' EL Phone W,6Mtratf, eS#A-f" Address _F 461- License N Phone �IF TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO SYSTEM REPAIR LI OTHER El 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 ❑ In��dus�•trial 171 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,}°Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications n Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump geek- H.P. a/ State Work Done y� \ f Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBeiow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f'l REPAIR/ADDITION I I DESTRUCTION I 1 lNo septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence— Commercial— Other Number of living units: 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, FU Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS i I Depth Size Number SUMPS Cl 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 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 S 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 rsons subject to workman's compensa- tion � Y Pe P P Y Pe 1 P tion laws of California." The appiic�a`tttt 4ustcall for all r q iced inspections. Complete drawing on reverse side. rj Signed Xtlf Cr-4+� Title: � 'C� Data: / r � OR DEPARTMENT USE ONLY ., I Application Accepted byro Date Area Pit or Grout Inspection by Date Final Inspection by Date -- awr Additional Comments: - C_F` cS ❑ Stk 466-6781 ❑ 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 95201FEE 1 j 1 INFO AMOUNT �DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMiT'NO. +.EH 13-241REV.rens! , ]fir fJ tJ ✓� UD 19 b . S EH 14-28 � I