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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 1 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. I A6.2Oq �0+�/e �. /�cl f/47'/d/ri�JrY Job Address City Lot Size PM I Owner's Name 7'ri tlg G�y �lry�;1'5 Address X 6 A C10 Mv W e-6 4 ��: Phone Contractor q(�y Address -0�-Z 1yL.1+%1'er7/#de License No. Voy'r,?/ Phan TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.D 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing r ._,.Specifications * Public n Other n Delta Depth of-Grout Seal Type of Grout - —� I I Irrigation _Approx. Depth l I Eastern Surface Seal-_Installed by Repair Work Done ❑ Type of Pumpt H.P. State Work Done_ r Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material )Below 50,) TYPE OF SEPTIC WORK: NEW INSTALLATION'L1` REPAIRIADDITIONX DESTRUCTION I I (No septic system permitted if public sewer is ' i available within 200 feet.) Installation will serve: Residence____ Commercial_X_ Other ' J y Number of living units: Number of bedrooms �� 69C L. i Fj' 5r,4 T1 oN , Character of soil to a depth of 3 feet: p Water table depth JJJ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Property Line I t LEACHING LINE ❑ No. & Length of-lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r I SEEPAGE PITS I ) Depth I Size Number SUMPS D Distance to nearest: Well 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 DiMrict. 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 must call for all required inspections. Complete drawing rnm��. Signed XJl� Title: Date: .3 9,0 (� OR DEPARTMENT USE ONLY - I Application Accepted by Vim. Date - �� 5-0 13t Pit or Grout Inspection by Date Final Inspection by L L1w��E�a•r� Date Z f 0 5 •t_ 1 Additional Comments: ❑ Stk 466-6781 fl Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE ! AMOUNT REMITTED CK CA H RECEIVED BY DATE PERMIT'NO. INFO +.EH13-24iREV.1/Nsl EH 14-26 [ [�