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r ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) „ . . :! "j' ' 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. 1 i Job Address _ ( ✓ Y �'L City Lot Size 2 Q X 01— PM _ ! Ownerdress 2— Q Yi A Phone S�`Z Contractor / Ir✓ r ddress ��> �►`t License No.f �Vy�D Phone!W J�Z Z TYPE ct WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES t DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL I PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 4 ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ; Type of Grout ❑ Irrigation _Approx. Depth j ❑ Eastern _ _ Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ { Well Destruction ❑ Well Diameter Sealing Material )top 501 a_ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑.INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other } 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. pMethod of Disposal i Distance to nearest: Well Foundation Property Line l ( � 1 r i LEACHING LINE ❑ No. & Length of Ii r Total length/size FILTER BED ❑ Distance to near i oundation Property Line! s< r 1 t F SEEPAGE_ PITS t ❑� Depth Size tuber S JMPS ❑ Distance to nearest: Well Cb AL Foundation Property Line x 1 DISPOSAL PONDS ❑ i I a I.hereby certify that 1 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 District. i 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." 4 The applica must call for I req ed inspe ions. Complete drawing on reverse side. ! C Signed X �� Title: tit,+"metol/L Date: �_ �.. FOR DEPARTMENT USE ONLY ti Application Accepted by Date�_-��' _ Area L y C—MPit or Grout Inspection by Date Final inspection by Date a Additional Comments: �� f✓ uM �i✓� ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +'EH13-24(REV.this) EH 14-28 /]fJ�J S`4 ! v