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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 TYEAR 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. 5A9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address �"k "r "f � f'"�"� City ✓ Lot Size PM #�.l Addres� . % 4,0► y- Phone-397- Owner's Name G� ! Contractor Address f i 9 � � _- License NP_ , Phone` r 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 P(TS/SUMPS ct� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `-; Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public 1-1 Other ❑ Delta Depth of Grout Seal f Type of Grout \ I I Irrigation -Approx. Depth l 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction -0. , Well Diameter Sealing Material (top 50') Depth" Filler-Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer isOZZ available within 200 feet.1 Installation will serve: Residence_ Commercial_. Other Number of living units: Number of bedrooms J /f ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg 't' ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Dis asap + ` Distance to nearest: Well Foundation J Property Line LEACHING LINE No. & Length of lines J Total length/size - -_ FILTER BED ❑ Distance to nearest: Well Foundation_... Property Line SEEPAGE PITS > J SUMPS ❑ Distance to nearest: Well Foundation l 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 Di1trict. 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 California." The applicant m&ut call for all required inspections. Complete drawing on reverse ide. Signed X T' kTitle: � F Date: FOR DEPARTMENT USE ONLY +Q Application Accepted by ti. 77 Date Area Pit or Grout Inspection by Da l Final Inspection b<--,'l Date o20 Y! Additional Comments: a ❑ Stk 466-6781 " ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA 8 INFO H RECEIVED BY DATE PERMIT'NO. Q •7] y��//p +.EH 13-24IREV,rix5) �.11 f.Q �1 V ✓�/ 1 EH 14-261