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jj APPLICATION FOR PERMIT C SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t) 37 y Telephone (209)`x- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �— y (Complete in Triplicate) Application is he+eby 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 SanJoaquin 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 ! y DLO _ _ t " City Lot Size �C PM Owner's Name , a�� tG' �FIe�A Address 9_3 a D E �MzELTO� �� one �e��Z' 3 3!F&' IIS � _._ Contractor Address License No. Phone_ TYPE OF WE NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PWIVIP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ 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 0O Open Bottom [1Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑I Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public ❑�Other F1 Delta Depth of Grout Seal �° Type of Grout __ 1 1 Irrigation ll-Approx, Depth !:I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 DfMpth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1] REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is i1` vailable within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: I1, Number of bedrooms 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 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ , Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have p6pared 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." .1� r The applicant must call for allren l required inspections. Complete drawing on reverse side. Signed X IY �'-'A� Title: Date: X FOR DEPARTMENT USE ONLY Application Accepted by I, Date ""`qeN a Area 1 Pit or Grout Inspection by J! Date Final Inspectio by Date ' Additional Comments: Ir 1 (5 /'6 I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ MaPAcca 823-7104 ❑ Tracy -6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 nFEOAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO.+.EH t3-24{REV,i/K EH 14-28