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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete 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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. � l ql�Job Address City Lot Size PM 117 Owner's Name �;p1 �" �t[G� Address /l 75-/ �O li Phone �� r ' r Contractor- 0 (1 Address License No. Phone `TYPE OF WELL/PUMP: _NEW:WELL,_O / WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LJ/ 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 # `# ❑ I nd Iai ❑ Open Bottom ❑ Manteca r Dia. of Well ExcavationDia. of Well Casing S4 omesticIPrivate ❑ Gravel Pack CITracy J Type of Casing t nr Specifications t"I Public n Other ❑ Delta Depth of Grout Seal I Type of Grout =T i I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump a H.P. State Work Done Well Destruction ElWell Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAIR/ADDITION 11` DESTRUCTION { 1 (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence— Commercial_ Other i r Number of living units: Number of bgdrooms; 4 T Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation [Property Line LEACHING LINE D No. & Length of lines t Total length/size I FILTER BED L] Distance to nearest: Well Foundation r Property Line t SEEPAGE PITS I I Depth Size i Number SUMPS Ll Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state law§, 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 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 persons subject to workman's compensa- tion laws of Calif nia." The-appliir in -Complet wing on Aid?", / Signed X Title: Daie22 ,S' ..'_:F.OR_DEPARTMENT;-l1SE ONLY— Application NLY Application Accepted by Date ' � _ Area r r Pit or Grout Inspection by Date Final Inspection by Date /-2� � A ditional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 , pplicant- 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 CASH RECEIVED 6Y CK DATE PERMIT'NO. 13-24{REV.1/8 51 CA �r- 1p �� EH 14-26 aLz ` r ✓