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APPLICATION FOR PERMIT oatkoj SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T 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. Job Address ^ City��,1 /yLot Siza� .!1�1— PM Address 11 i 3 �s�5 __ Phone - Owner's Name _ C ` 1 i��I l �U Address License No 1 Phone `t Y ontractor TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION�I SYSTEM REPAIR ❑ OTHER 1-1�R / i DISTANCE TO NEAREST: ASEPTIC TANK , � ,r SEWER LINES DISPOSAL FLD./�L,L PROP. LINE �- a FOUNDATIOI ._.- 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_ Specifications_ FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout l 1 Irrigation -Approx. DerptFh� t I Eastern . ..,Surface Seal-Installed-by.. Repair Work Done Q( Type of Pump s�[df -._. H:P. State Work Done Well Destruction D Well Diameter') Sealing Material (top 501 Depth Filler'Material-(.Below 50') —_ TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I I 'DESTRUCTION I I (No septic system permitted if public sewer is l available within-200 feet-)- Installation will serve: Residence—r f Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: '4 Water table depth SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line .I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I 1 Depth . Size Number SUMPS Ll 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 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 California." The applicant sil,call for all required ins cti n . Complete dra 'ng onreverseside. Signed X Title: l a �� Date: t FOR DEPARTMENT USE ONLY i Application Accepted by Date - Area Pit or Grout Inspection b� Date/ Fina Ins action by Date Additional Comments: IWK' -��40� -,� ❑ Stk 466-6781 ❑ Lodi 36946211 ❑ Manteca 823-71 ❑ Trac 835-6385 A Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOfUNT DUE °t. jAMOUNT REMITTED CK ASH RECEIVED 9Y DATE PERMIT'NOg. EHt3-24 MEV.1/851 '1 1 �_ y(] f JV /' } EH 14-28 fff /Jc4/ k l