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APPLICATION FOR PERMIT tJ 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) 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. Job Address :2- City Lot Size PM 4r Address . Owner's Name T Address °�'"°"" Phone Contractor�� Address PZ_<-V-P& ;57+ rlA/ License NliPhone -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER. ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE-OF-WELL.,.,.._.RROBLEM.AREA._-_CONSTRUCTION-SPECIFICATIONS, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty g Specifications f 1 Public f-1 Other C-1 Delta Depth of Grout Seal Type of Grout I Irrigation __.Approx. Dept astern Surface Seal Installed by _ Repair Work.Done ❑ Type of p H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material stop 50`1 Depth Filler Material (Below 50') ' r -�— TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTIO No septic system permitted if public sewer is I ) Installation will serve: Residence_ Commercial_ Other Number of,living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 11 i Method of Disposal { Distance to nearest: Well Foundation Property Line � f LEACHING LINE ❑ No. & Length of lines Y —,Total length/size FILTER BED ❑ Distance to nearest: , Well SFoundation Property Line i SEEPAGE PITS i I Depth Size °' I Number SUMPS ❑ Distance to nearest: Well Foundation t Property Line DISPOSAL PONDS ❑ _71!'"'..". 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 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." - The applicant st call for 114required inspections. Complete drawing on reverse ide. f ` Signed X t — - Title:_ Date: FOR DEPARTMENT USE ONLY la 4� 1y mss" i tt- l� V l Application Accepted by � _- t. , pate i Area � Y Pit or Grout Inspection by Dat Fina�spection by Date I iditional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&395 plicant - 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. '°(: A RECEIVED BY DATE PERMIT'-NO. + a EH 13-24)REV.tin 5) �Eog 1. `J�^''ev 1r 7_ �!['' EH 14-26 �V � �� [ 1�`� -- P--12707