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i Nik i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x �� _;;. •, , # �' ., : (Complete in Triplicate) described. This application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein made in compliance with San Joaquin County Wdinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin !�! Local Health District. 27 Job Address City /-fy — Lot Size 6 PM Y Owner's Name Address al XZ0 l]` IV,`F`'►4 Phone Contractor's Nam i License No. 3e r/2 Phone, .0? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE �.- 17 FOUNDATION t 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 R ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout.Seal. Type of Grout ❑ Irrigation _._,_._Approx. Depth ❑ Eastern Surface Seal Installed by N Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well'Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRUCTION Ll (No septic system permitted if public sewer is z I available within 200 feet.) Installation will serve: R dence �mmercial .-Other Number of living units: Number of edrooms .2—. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg'[-4 dl Capacity 1 �� No. Compartments I PKG. TREATMENT PLT.❑ t ( Method of Disposal Distance to nearest: 'Well�� Foundation �+� Property Line �x { LEACHING LINE ; No. & Length of lines 4�. .. Notal length/size FILTER BED Q�Distance to'nearest Welh AA 56 c _'Foundation r _ Property Line I� SEEPAGE PITS bepth _Size i � ��Number _ r SUMPS ❑ Distance to nearest: Well�-_t.'`Foundation��, -_ Property Line t DISPOSAL PONDS �❑ ,1 x�'�`- """."`. TZs• 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. a, 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,Cal--rfornia.;'Contractors'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 I e fired inspections. Complete drawing on reverse side. a Signed 11' Title:�,_ Date: -,2 i FOR DEPARTMENT USE ONLY ? i 1 �S� ` Application Accepted by � �� 9 Date,� Area ..f:5j-- Pit r Grout Inspection by Y Date t? Final Inspection b w Date Additional Comments: * `J`' ❑ Stk 466-6781 ❑l Lodi 369-3621 ❑ Manteca 823-714--."❑ Tracy 835f385 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 CASH RECEIVED BY DATE PERMIT NO. INFO aw EH EH 1426 13-24(REV.101831 i