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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 San Joaquin County Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` �SgI Job Address I {, LL � � - G!a vj D City�� Lot Size PM V Owner's Name �` L L 1 Address // Phone Contractor L Address T License No. 30 -D 9 Phone fiJS LTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t. fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ I 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 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 AIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is � available within 200 feet.) � Installation will serve: Residence�Lommercial Other Number of living units: _ Number of e(drr000mms_ 7 Q Character of soil to a depth of 3 feet: 61 It-! ( .('./._��1i' '� �___ `` Water table depth LSEPTIC TANK ❑ Type/Mfg C n til r Y — Cap ity �LJVo. Compartments PKG. TREATMENT PLT. ❑ q�� V Method of. Disposal Distance to nearest: Well C�4LLL Foundation _ Property LineC LLEACHING LINE M-44o. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line LSEEPAGE PITS ILyOeplh e - Size Number SUMPS LI Distance to nearest: Well Foundation Property Line LDISPOSAL PONDS L1 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: "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-LCalifornia." Contractor's hiring or subcontracting signature�'celi s the following: "I certify that in[he performance of[ha work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws California." The applican s call or II re fired i s cti – late drawing on J arse sl Si netl Title: ` Data: `' FOR DEPARTMENT USE ONLY � 'I Application Accepted by '\�. Date C � r Area \–> LPit or Grout Inspection by Date Final Inspection by Date Additional Comments: LI¢�Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 835.6385 {Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE L INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. EH ta.24IPEV.irxel (. . �j,� glaI (�� 33 •t� EM N-M w l Jl 6 1 L