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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT T 1601 E. HAZE T ON AVE., STOCKTON, CA (l Telephone 12091 466-67811174 4 1, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICDmplete 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. 11862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 91072=n �y�►,�� City Lot Size PM Owner's Name Address 7aL Phone Contractor V Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.E] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ R DISTANCE, REST: SEPT_IC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial-� ❑ Open Bottom ❑ Dia. of Well Excavation Dia. of Well Casing . ❑ Domestic/PriJbte ❑ Gravel Pack ❑ Tracy Type_,Qf Casing Specifications 171 Public ❑ Other ❑ Delta Depth ofGro Type of Grout I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of.Pump H.P. State Work Done T A�1 r Well Destruction-- ❑ Well Diameter Sealing Material Itop 50'1 f Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION )k REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is a A available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms { Char actof of soil t a pth of 3 feet: ..Water table depth m IrSEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t ' Distance to nearest: Well Foundation 2_LQ Property Line [� LEACHING LINE ❑ 'No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS CI 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 courity ordinances;,state laws, and rules and regulations of the San Joaquin Local Health District. = .j. 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,l shall employ persons subject to workman's compensa- tion laws of California." The app- call al requir i pections. Complete drawing on reverse side. 1 f t Signed X Title: T vt'7i11. A ...____.,,__. Date: FOR DEPARTMENT USE ONLY Application Accepted by `� ��Y� Date ` - O_ Area Pit or Grout Inspection by /� ,y Date Final Inspection by Date 5 Additional Comments: .�v/�G��M zY&,,ylt ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 a I f FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT-NO. � INFO , �. 12 7M EH13-21(REV. EH 14-26 V L