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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT L r 1601 E. HAZELTON AVE., STOCKTON, CA (� Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED L I,' (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 k Local Health District. Y q � ,, Job Address /9G- [- 9Jee,,_-fGl.,Z ,F:� - City Lot Size / h PM Owner's Name �t_(g`�i Address Phone Contractor V e2,677,_Address �n � _2�G License No r1. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 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 M Public Cl Other Fl Delta Depth of Grout Seal Type of Grout _ \ I I Irrigation >: Approx. Depth I 1 Eastern Surface Seaj lr sialied by Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTIONNa septic system permitted if public sewer is vailable within 200 ,, -installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �µ Dist Ice 4o a EXP da i n Property Line ^i WfthOUt LEACHING LINE Cl No. & L ngr btu illl } k�C Total length/size FILTER BED ❑ Distancs�g�m�e'a�i ing � Lei Orf ;L4 Property Line SEEPAGE PITS [ I Depth Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 D1✓;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, 1 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: N 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 mus alt for a7fl'reu inspec' s. Complete drawing on reverse side. Signed Title: pate: 1�;Il_ff FO PARTM_E_NT USE ONLY Application Accepted by Date Z Area 10 Pit or Grout Inspection by f t7r� '{ r{- Date y it al Inspec o y Date Additional Comments: w ❑ Stk 466-6781 , ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton.Ave., P.O. Box 2009, Stk., CA 95201 INF FEE_ I MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE m PERMIT'NO. +.EH1324(REV.1ik5) b !'!/�1 I ✓Y�/ �" EH 14-26 I