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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEVON 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. Job Address2311 /_f City Lot Size PM Owner's Name �/ ress /�/�/ /° fjd ✓�� Phone �( Contractor Address_ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P � F)!-,) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER AD C;;W,-JA*;1y 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 Cl Manteca Dia. of Well Excavation Dia. of Well Casing W Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _. OD i I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done LJType of PumpH.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 501 fll.Eit.�-- �lti9f/�G� d1�j�C7 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I 1 DESTRUCTION l I INo septic system permitted it public sewer is -�[i available within 200 feet.) 1 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. ❑ j :S c } Method of Disposal Distance to nearest: _ Well Foundation Property Line LEACHING LINE ❑' No. Length of lines Total length/size FILTER BED ❑ Distance to.nearest: r- ;,Vtielt=--- Foundation Property Line 1 SEEPAGE PITS I i Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this?appiication Ad tt at'the work will be one in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health)Daridtt the)ollotvirig: Itt ertify'that In the performance of the work for which this permit is issued, I shall not Home Owner or licensed agents signature certifies employ any person in such manner as to'become subject to work' an'scompgn ation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in ihe;performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ` r The applicant s aN equired ,� s. Complete drawing on rev so side. Signed X � Q Title: / - Date: FOR DEPARTMENT USE ONLY Application Accepted by � , "Date 12 1Z, Area 15 Pit or Grout Inspection by Date Final Inspection by /� Z Date yzTr-d- Additional Comments: ❑ 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT ^REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. ♦.EHt3-241REV.i/H57 Opp EH 1428 V f