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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E..HAZELION AVE., STOCKTON, CA Telephone (7% 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 � ��p Lot Size PM �^ k � 1'�✓�� A • �Q Phone -©I ) Owner's Name ddress FTW' Contractor's Name t `License No.' `+' Phone �I # TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION PUMP WSTALLAT10N-._l ,� ��`' .SYSTEM REPAIR LIOTHER Q + j; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -- INTENDED USE TYPE OF WELL PROBLEM AREA —CONSTRUCTION SPECIFICATIONS r: d Dia. of Well Casin ❑ Industrial ❑ Open Bottom ' ❑''Manteca' Dia. of Well Excavation g . :LL Y � Specifications ❑ Domestic/Private ❑ Gravel Pack " ❑ Tracy Type of Casing I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑.Irrjgation i` � _�pprox. Depth ]„Eastern Surface Seal Installed by —Z: State Work Done _Repair Work.Done ❑ Type of Pump; H.P. - I Ir%: Sealing Material Itop 50'1 Well Destruction, ❑ Well`Diamete`r: . Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEIN INSTALLATION REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r ` available within 2 00 feet.) O :p �ATt*MM Installation will-serve: ResidencerCommercial ther r Number of living units: `' Number of bedrooms l , Water table depth c y Character of soil to a depth of 3 feet: r2- - _ v T ._C{pac.i�ty - Na. Compartments -TANK ..Tpe/Wg ` .a 1SEPTICF "ik � Method of Disposal ff PKG. TREATMENT PLT. ❑ y, r i Distance,-to nearest-'-A W&II�—{`Foundatiori �J Property Line�— a LEACHING LINE No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well _+ Foundation 1) Property Line Sin - SEEPAGE PITS Depth -Size Number SUMPS El Distance to nearest: Well .— 3Foundation Property Line;SZ2 DISPOSAL PONDS ❑ 1 I hereby certify that I have prepared this application and that the work will be dobe in accordance with San Joaquin county ordinances, state laws, and j 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 ch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin I certify that in the pertorma a of the'work for,which this permit is issued,I shall employ persons subject to workman's compensa- I tion laws of Califo i ." ! J f The appli t st or all req ed ins on Cam ate drawing rev k i ' Signed Title: Date: �. -•-FOR DEPARTMENT USE ONLY F.. .a-; ('� _ Date tea" Area - S Appl)catio,n Accepted by ;'' - g ete�-7 Prt,or Grout-Inspection by Date `I Final Inspection by � !! ,b el tj ' r Additional Comments: �^'9 Psld A L i a L] Stk 466-6781 ❑ Lodi X369 3621 ❑ Manteca 823 7.104__ ❑ Tracy, 835-6385 m_ ' Applicant- Return.all to: Environmental Health Permit/Services 1601 E{ Hazelton Ave., P:4 .Box 2009'StR:,`CA 95201 �.>��.� EEE AMOUk7"6UE-ter AMOUNT-REMITTED-�CASH .RECEIVED BYE - ,DATE- �-PE��T.,-N� �- T _..._INFO'• �.- ....�.- �; D 7-3��l m--gi - + EH 13-24 iREV.10153) EH 14-25 -