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I APPLICATION FOR PERMIT n SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON 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. ufttl �r Job Address � City ``r 'C� Lot Size PM r Owner's Name �z Address Phone I Contractor I1 �� t� Address Q aucu''i R11r'License No.29-3-1/B Phone TYPE OF WELL/PUMP: eF NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER EJ ��1' DISTANCE TO NEAREST SEPTIC TANK`"""'"""`—SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELt PITS/SUMPS F INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t . ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Cas ng ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i"i Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx, Depth I I Eastern Surface Seal Installed by I Repair Ark Done ❑ Type of Pump H.P. � State Work Done Well Destruction ❑ Well Diameter Sealing Material (top,50') Depth Filler Material (BeIZ 50') y' ` TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION-1 --DESTRUCTION 1.1+(No septic system permitted if public sewer is N Y ! ;,,,�' ,."available-withiq-2D0-feet•.-I--.....••.K-�-.—;...�•.—,�•a`� Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 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 No. & Length of lines ^ Total length/size �v FILTER BED ❑ Distance to nearest: Well f=oundation Property Line , SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well !Foundation Property Line ct DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county rdinances, state laws, and rules and regulations of the San Joaquin Local Health District. �* Home owner or licensed agent's signature certifies the following_- certify that in the performance of the work for which this permit is issued,-1 shall nbt employ any person in such manner as to become sub"ect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perform. a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantLew for all requir nspections Complete drawing on reverse side. t �} i rtt Signed X Title: �✓ Date: ^ �� F f)EPA MENT USE ONLY Application Accepted by Date / ' rea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ _ C1Stk 466-6781 ❑ Lodi 369-3621 O-Writeca 823-7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH + EHt3-24 IAEV.t i H 57 EH 19"26 _I