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APPLICATIOkFOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT No 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 M. • !YE 0—kA (Complete in Triplicate) s 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 1. .,.- ,: �r •.: ,."[tl�,.-:r Job Address © 3 f F S _ i i/ ;i IC " :14 e, 1 City S T Lot Size U x 3 v PM 1 Owner's Name r VvL' t% ►p,r ,Lj'"C-ke C, ddress Phone y Contractor S -_1. Address TYPE OF WELL/PUMP: License Na. Phone 0NEW;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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation (j ❑ Domestic/Private ❑ ❑ Tracy 1 Grave! Pack Dia. of Wel! Casing V ❑ Public ❑ Other r� Ype of.Casing Specifications er ❑ Delta Depth of Grout Seal ❑ Irrigation Type of Grout —.__Approxi Depth ❑ Eastern Surface�Sea! Installed by �-. Repair Work Done ❑ Type of Pump H p State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 501) Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Installation will serve: Residence T{ Commercial y vailable within 200 feet.) Other { Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:1 SEPTIC TANK "' ❑'� Type%Mfg ! p Water table depth Capacity No. Compartments PKG, TREATMENT PLT. ❑ � E,JY Method of Disposal Distance to nearest: Wel! Foundation f i 1 Property Line LEACHING LINE ❑ "'; . - No. & Length of lines Total length/size FILTER Bib ❑ Distance.to nearest: Well - I Foundation Property Line----------------------- J SEEPAGE PITS ❑ Depth f Size Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS Property Line 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: "1 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." 1 The applicant must call for all required inspections. Complete drawing on reverse side. Signe pX-��j is / -� Title: tC'`C`� Date: ' - 1 -�E>–:� FOR DEPARTMENT USE ONLY Application Accepted by W _S%&ArAC _ Date 4 0" Q Area Pit or Grout Inspection by Date ate Final Inspection by Additional Comment "cf ❑ Stk 466-6781 0 Lodi 369-3621 s ❑ Manteca 823-7104 q Tracy 835-6385 Applicant- Return all Copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE' AMOUNT REMITTED CK INFO RECEIVED BY DATE PERMIT'No. + EH1 -24fREV.'I/n51 EH 144-28