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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 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 14waitions of the,San Joaquin Local Health District. u'• ' �. i,4' Job Address rVt Raw s� iT rU, 13 City AKAy/y_ Lot Size r%tl' `- PM Owner's Name Address Phone Contractor L �6�/uS Address 14'9, 001 'A „�� f'- License No, Phone 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 FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel!.Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casing Specifications 171 Public ❑ Other. ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Dane_ Well Destruction [A� Well Diameter J Sealing Material (top 50') , CTFu> f 14✓Y7 _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIWADDITION l I DESTRUCTION.I I {No septic system permitted if public sewer is available within 200 feet.) 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. ❑ Method of-bisposal Distance to nearest: Well x' Foundation Property Line LEACHING LINE ❑ No. & Length of lines r dToibl length/size FILTER BED ❑ Distance to nearest: Well Foundation.— Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ 1 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 Diltrict. 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 shalt 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,1 shall employ persons subject to workman's compensa- �L , tion laws of Calif nia." The applica st call all�re�ired inspections: Complete drawing on reverse side. f / Signed Title: t ��LQ 7 13 r -_ Date: rQ:Z7– t T .. OR [ PARTMENT USE ONLY r .5.�\Jlr Application Accepted by \ a .A�r-.^C�nr.�: Date D ea }},, Pit or Grout Inspectiy Date Final Inspection b Dat�`� r� ' ' Additional Comments; 2irbrim ❑ Stk 466-6781 ❑ Lodi 21 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies toental Health Permit/5arvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO A�yMOr-U-NT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. +-EH14-28 3-24(REV.5 i x 51 EH 1