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APPLICATION,FOR PERMIT S i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r , . (Complete in Triplicates Application is hereby made to the San_Joaquin Local Health District for a permit to construct and/or install the work herein de c'ribed. THs application is made in compliance with San Joaquin Cdunty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District: ,��f T v n� •a � J Job Address5 City �/ /C Lot Size PM Owner's Name �__�A�Qi" C��/7'r Address �7 3��/ Phone Contractor r Address License No. Phone F TYPE 0tF WELLIFUMP: NEW WELL ❑ WELL REPLACEMENT ❑� DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-, NE FOUNDATION AG OTHER WELL PITS/SUMPS INTENDED USE TYPE OF ZEL.L �10�BLIM AREA 'CONSTRUCTION,SPECIFI �J❑ Industrial E ❑ Open eca Dia. of Well Excavation f Well Casing I ' # ❑ Domestic/Private: ravel Pack ❑ Tracy Type of Casing Specificatio s` € ❑ Public t ❑ Other-47--- ❑ Deifa Depth of Grout Seal Type of Grout ❑ Irrigat" �gppr:".:Depth C�Ea'stem Surface Seal Installed by Repair Work Done ❑ Type of Pump �j '.14 H.P. State Work Done Well Destruction '❑_ Well Diameter Sealing Material {top 50') # t i Depth 1 Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION (No septic system permitted it public sewer is tt available within 200 feet.) Installation will serve: Residence— Commercial_`• Other Number of livingunits:_ __ Number-of.-bedrooms 7-= 1 Character of soil to a depth of 3 feet: "�'� _ . Water table depth SEPTIC47ANK ❑ Type/Mfg _+ Capacity ., tNo. Compartments ' PKG. TREATMENT PLT. ❑ ) C Method of Disposal ; Distance.to nearest: WelF r Foundation Property Line LEACHING LINE ❑ No. &'LjAgth"of lines Total length/size t " FILTER BED ❑ -Distance-to.nee rest: Well ° Foundation Property Line t SEEPAGE PITS " ❑ Depth )#� Size Number SUMPS'. .❑ Distance to nearest: Well Foundation tProperty Line t DISPOSAL PONDS ❑ � I herebyjcertify 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. t "� i Home owner or licensed agent's signature certifies the following:'"l certify that in the performance of the work for which this permit is issued, I sFiall not employ any person in such manner as fo become subjecHo workman's compensation laws of California." Contractor's hiring oi,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." r The applicant must call for all required inspections. Complete drawing on reverse side. s 1 Date: Signed �9 Signed Title: FOR _Q&PARTMENT USE ONLY Application Accepted by 11 Date Area �f Pit or Grout Inspection by Date Final Inspection by Date 3 17 Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3f21 ❑ Manteca .823-7104 ❑.Tracy 835-6385 Applicant- Return all copies to: Envirortriiental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE -'CK.#- _...�..„ w AMOUNT DUE�- AMOUNT-REMITTED ""RECEIVED BY PATE PERMIT'NO. .._.,,... .,.....-"INFO + EH 13-24(REV.+/H sl „ rte. .a - E EH 14-28