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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hefeby 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. r Job Address ' ilv6aa Cit <7nZ y,� mot Size PM Owner's Name ,tJ „____ Address �/�jp _ _ Phone / 4 V ©• ��s/% /�fr�� Contractor /.�� Address License No Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ x DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ( , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation --Dia. of WWII Casing' - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy .� Type of Casing Specifications FI Public 171 Other 11 Delta' Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I.I.Easterri' Surface Seal Installed by ,Repair Work Done . 0- Type of Pump H,P. State Work Done Well Destruction O Well diameter Sealing Material (top 50') Depth Filler Material (Below 50.') _� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITi6_Wi I DESTRUCTION I I jNo septic system-permitted if public sewers �' 1a available within 200 feet.) x Installation will sbrve: _Residence-AL Commercial Other i Number of living units: Number of.bedrooms + feet: Water table depth. Character of soil to a depth of 3 3 SEPTIC TANK ❑ Type/Mfg . `1 ; 1 :Y- 2Q No. Compartments” PKG. TREATMENT PLT. ❑ y k Method of Disposal Distance to nearest ., Well -Foundation__Z0 Property Line LEACHING LINE No. & Length of lines'-- --�2 / << Total length/size 4,ee) FILTER BED ❑ Distance to nearest: Well A"Foundation_Zd Property Line k SEEPAGE PITS i I Depth Size,' Number SUMPS U Distance to nearest: Well'o 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 Di§trict. 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." C'ontractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thisp p ermit is y persons subject to workman's compensa- tion laws of California." issued, I shall employ � F The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: ` rp FOR DEPARTMENT USE ONLY f7 i Application Accepted byDate+ ��—ol0 Area A) 4 1 Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED' CK 49 ASH RECEIVED BY DATE PERMIT'NO. +.EH 13-21(REV. S) Q /�l - EH 11-28 rCJ r