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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA F Telephone (209) 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. a Job Address 3 p2Z)i el � ©�j f T � .rty Lot Size PM Owner's Name ��rAr✓/S/ l SAN � - dress � hone Contracto '>2. Address License No. 6 I Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DES7RUCTIDN PUMP INSTALLATION C1 °"' l SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK: SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION{ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing _ 1-1 Public Specifications y ( f Other C� Oelta Depth of Grout Seal I I Irrigation Type of Grout _ g _--Approx. Depth i l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H p - State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION ! I fNo septic system permitted if public sewer is Installation will serve: Residence_ available within 200 feet.) r _ Commercial, Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth s ❑ Type/Mfg Capacity 7 PKG. TREATMENT PLT. f-1t No. Compartments Method of Disposal Distance to nearest: Well Foundation Property Line )I LEACHING LINE f 1 ❑ No. & Length of lines t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line d SEEPAGE PITS I 11 Depth Size SUMPSNumber i L1 Distance to nearest: Well 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 HealthSDRtrict. 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 empl tion laws of California." oy persons subject to workman's campensa The applicant must callforall required inspections. Complete drawing on Averse side. SignedCC � i Title: _ -2h Date: I,C FPARTMENT USE ONLY _r3 11 Application Accepted by 5 �� ' C 1,,2f Date Area L7 Gln Pit or.Grout Inspection by bate �m pf Final Inspection by � Date _ Additional Comments: 4 i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 � I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` FEEAMOUNT DUE x AMOUNT REMITTED C INFO ASH RECEIVED Ely DATE PERMIT'NO. + EH 13-24 IREV,r i H 57 EH 14-26 .CJ,r,' �Z �3 .