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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) k 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 � City I'//Z'g;,7 Lot Size PM Owner's Name `AWAddress Phone l ! Contractor .e Address 24A4 . 1 9P License No. � �/� Phone °TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ pDESTRUCTION E1 PUMP INSTALLATION,-C7 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 Dia. of Well Casing J0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �. l7 Public ❑ Other r ❑ Delta Depth of Grout Seal ; Type of Grout i I 1 Irrigation "—.-Approx. Depth l I Eastern Surface Seal Installed by V r Repair Work Done ❑ Type of Pump H.P. r j _ State or one ffA - II Well Destruction ❑ Well Diameter Sealing Material {top 501 55 eq&LJ:L� Depth Filler Material {Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1.1 DESTRUCTION l I (Nb septic system permitted if public sewer is available within 2001eet.l Installation will serve: Residence— Commercial_ Other Number of living units; Number of bedrooms , Character of soil to a.depth of 3 feet: Water tattle depth - SEPTIC TANK ❑ Type/Mfg Capacity Y ` �J_!��. - _No. Compartments �.��F.-•---f $Method of Disposal PKG. TREATMENT PLT. ❑ � y^°" ., �.,� ��,y� � �. � Distance to nearest: Well Foundation, Property_Line LEACHING LINE ❑ No..&Length of lines �' "-'` �1 � ^i Totaheng`h/sizeT� FILTER BED ❑ Distance to nearest:___lWellFau`ndation Property Line SEEPAGE PITS I i Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line i, DISPOSAL PONDS ❑ j 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. r 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 t�atin the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r I Theapplicant s cal for all r u' inspections. Complete drawing on reverse e. Signed X_ :f ^. /G�i�� Title: r� rii e� Date: �/,�` FOR DEPARTMENT USE ONLY J D Application Accepted by � _-- Date Area (VJ_ j Pit or Grout Inspection by + Date Final Inspection by Dater F Additional Comments: ❑ 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 f INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 tREV.r/K51 EH 14-2e ^""