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i 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. JJ � ,,IA ,,� Job Address �� _ CityLLot Size ` /`�'1�"�PM Owner's Name V ffAddress Phone {� Contractork— 1 Lft \YkL L Address ___1t->50 CL '+License No.qa09t_Phone 124 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 _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack 0 Tracy Type of Casing Specifications 1`7 Public [_l Other F1 Delta Depth of Grout Sea! Type of Grout I y I I Irrigation' _..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done_ r, Well Destruction ❑ Well Diameter Sealing Material atop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION I i DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) r - Installation will serve: R ldence Commercial Other ^, Number of living units: Number of bedrooms _2> Lha Character of soil to a depth of 3 feet: Water table depth ``:/ SEPTIC TANK N--fiYpe/Mfg Capacity__./.;142L(=1_ No. Compartments PKG. TREATMENT PLT. ❑ `. C far (C �' Method of Disposal Distance to nearest: Well Foundation_O Property.Line LEACHING LINE NL--PK.-& Length of lines 1 g �Otal length/size — —` FILTER BED ❑ Distance to nearest: Well Foundation U Property Line 311 SEEPAGE PITS 1`I-11-epihSize Number SUMPS Ll Distance to nearest: Weil FoundationProperty 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 01wtict. 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 certitkq 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 lawsCalifornia The applica t s all for all s. C rn drawing an re se side. Sign tle: bate: c� r �t;f I-e - - FOR DEP RT T SE ONLY Application Accepted by Date �'� Area Z I ,!i r Grout Inspection by Date Final Inspection by. Date + -r Additional Comments: , 27 '�°} L15tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 04 ❑ Tracy 635-6385 G' cS�y�'� 7 h Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201�Gc�Lil a ray FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH 1 •.EH 1324(REV.r i H 51 SE: �. EH 14-28