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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Z 1601 E. HAZE T ON AVE., STOCKTON, CA 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 Sari Joaquin County Ordinance No. 549 for sewage or No. 1B62 for welllpump and the Rules and Regulations of the San Joaquin f Local Health District. �Job Address / 5 ' _-_ /uL- �o �l�1 �-)_ City Lot Size PM Owner's Name 43ELG"L ( L C� l 1 ((h Address L� C ' f �1�7 >`I�- Fion�� 7 7"�� Y! Contractor /`�-(4 ,lCi ! -, Address (�C/cLzLt(E' JQr o— C- License No-�fZ13_Phone TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ fee PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Jam., SEWER LINES DISPOSAL FLD.196�PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 1n5 , PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing eY Yt' Domestic/Private Gravel Pack ❑ Tracy Type of Casing I Specifications F1 Public 71 Other Cl Delta Depth of Grout Sea! Typo of Grout .__. I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50 a Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION 111No septic system permitted if public sewer is s r' available within 200 feet.) V Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth M I 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 ( I Depth Size _ Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 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 I rules and regulations of the San Joaquin Local Health District. 3 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 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature t 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." The appli_c ust tail for all req d inspections. omplete drawing reverse si Signed X Title: Date: FO DEP TMENT USE ONLY Application Accepted by Dater —� �° Area 1 �I Pit or Grout Inspection by Date final Inspection by [}ate -3 tt I p Additional Comments: n V� y� �• �ti � ❑ Silk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 325' INFO AMOUNT DUE AMOUNT EMITT CASH CK 4 RECEIVED Y DATE PERMIT'NO. + EH 13-24(REV.t i n 5) EH 14-26 t Q�' ll t._�