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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA [ � Telephone (209) 466-6781, ; i Y� PERMIT EXPIRES TYEAR 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. crA,o.P f- Job Address City �ifc!1� Lot Size_5 CJ PM Owner's Name R` E= Address Phone Contractor ry Address Or License No. -Iphone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom E! Manteca Dia. of Well Excavation Dia. of Well Casing : Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout .. I I irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump i H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') ! Depth wx Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION RE-,PAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) s � Installation will serve: Residence_Ae'Commercial_ Other _ ,Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: " -Water table depth SEPTIC TANK 7K Type/Mfg. Capacity_, No. Compartments PKG.TREATMENT PLT. ❑ /� _` � Method of Disposal Distance to nearest: Well i � ---- FoundationProperty.Line;`�C5"� LEACHING LINE No. & Length of lines /"J 0=7- Total length/size i FILTER BED ❑ Distance to nearest: Well lehOr�=f Foundation AZZ2 Property Line 'f . a SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t r I hereby certify-that l-have prepared this appileation 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. 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 d 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." - A— I he applicant must call f all re wired inspections. Complete drawing on reverse side. a t ' t t l Signed X Title:. �*�-ccaf-s Date: 3 FdRWDEPARTMENT USE ONLY, . . E :Application Accepted by � Y � � ` � p Date � Area l6 3Inspection4? U Date�= Final b Date Pit or Grout Inspection byy Additional Comments: ` "e- t ❑ Stk 466-6781 ❑ Lodi 369=3621 O Manteca 823=7lO4"" L]-Tray 635-6385 Applicant - Return all copies to: Environmental Health Permit/-Services 1601 E_Hazelton_Ave ,-P.O. Box 2009, Stk., CA 9520.1 f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY. DATE PERMIT NO. INFO CASH . - 13-24 IRI-Y.^t/.x:5] Jt`...., :_/ ,..-........ � EH 14-26 _ ' 1