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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZEILTON 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 Address _ �a`�• /�/t , City Lot Size— PM Owner's Name _, • Address 1 _ Phone Contractor's Name d/�'� ,_ License No. er� -- -- Phone9_3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION Q PUMP INSTALLATION. ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE —_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom F1 Manteca Dia. of Well Excavation Dia. of Well Casing V7"Domestic/Private ❑ Gravel Pack ❑ Tracy Type of of GCasing Specifications LJ Public ❑ Other ❑ Delta Depth Fout Seal Type of Grout ❑ Irrigation ---Approx. Depth P Eastern Surface Seal Installed by Repair Work bone ❑ Type of PumpH.P. / State Work Donk Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth w'. Filler Material (Below++50' GIN 1' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,,.REPAIR/ADDITION ❑ .DESTRUCTION ❑ (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 r `{ l� Character of soil to a depth of 3 feet: Water table depth ` 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal a 17istance to n8arest: Well Foundation Property Line J LEACHING LINE ❑ No. & Length of lines 1 3 Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well f 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. t 4 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 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 f9r which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ' The applicant ust call f II required inspections. Complete drawing on verse side. Signed X E Title: 4iya.t-i. Date: FOR DEPA TM ENT USE ONLY �Q t Application Accepted by w Date " ` Area /X Pit or Grout Inspection by Date _ Final Inspection by Date L�S Additional Comments: — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C7 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services ISM E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO. INFO -7�13-24 IRM WWI �[S�-'acs ��' �.1'� " ��f�s �� l 14.26 -1