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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1609 E. HAZELTON AVE., STOCKTON, CA r 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. p?1Ksr0 ,,/,` W v�� _f . t Job Address Q� � lv � Treoo7 ",POL_ , • � ' (.� ,�/ J City (� t Size f M f Owner's Name Q+ / f Lt't�Cly R_ Address _( d a � Phone Contractor 6AI"P r, Address`" {f 0 All License No._%;_-�� Phone TYPE OF WELL/PUMP:- NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATON ❑ x, rr, , SYSTEM REPAIR L2OTHER ❑ - (n DISTANCE TO NEAREST: SEPTIC TANK D 'p, SEWER LINES # DISPOSAL"FLD. PROP. LINE) FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PR BLEM AREA CONSTRUCTION SPECIFICATI S lI I ❑ Industrial ❑ Open BottomNlanteca Dia. of Well Ex vatio d Dia. of Well Casing ❑ Domestic/Private ravel Pack Cl Tracy Type of Casin_� r Specifications Public ❑ Other ❑ Delta Depth.of Grout Seal Type of Grout &01 A't 259 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ T p p. Type of Pum H.P. Stat Wo k Do.e_ 0 Well Destruction ❑ Well DiameterSealing Material (top 50') � t, +, Depth Filler Material (Below 501 17� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available Within 200 feet.) Installation will serve: Residence_ " Commercial_ Other i Number of living units: 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number r SUMPS ❑ -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 Health District.. f Home owner or licensed agent's signature certifies the follov✓jng: "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 sub( t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performancof the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant X11 for all rairinspections. Complete drawing on verse side. Signed X Title: [µif Date: FOR DEPARTMENT USE ONLY y� = 1 Application Accepted by Date � �� Area Pit or Grout Inspection by Date L_ ' Final Inspection by Date Y ra itional Comments " S'0 W- 4 tk 466-6781 L1Lodi 369-3621 Manteca -7104 L1 Tracy' 5-6385 %'' ' plicant - Return all copies to: Environmental th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT•NO+. + EH 13-24 IREV.I/x 51 �•,• /� % - � EH 14-28 a..