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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. j ) Job Address `l S 2 /&2Z-24i—j �� ° "(," City Lot Size�t _ PM -SL Sv owner's Name Address 1 S' /V • -�� 'y^ T .,.0 Phone ' Contract V 0lddress ZAlu'a"�,cense No Phone TYPE OF WELL/PUMP: NEW WELL /' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK J O SEWER LINES DISPOSAL FLO. e'0 PROP. LIN15-14 C FOUNDATION 3,0 AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI •J el ❑ Ind at n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal _S Typ 3of I I Irrigation —Approx. Depth I I stern Surface Seal Installed by - Repaii Work Done ❑ Type of Pump H.P. State Work Done_ \� Well Destruction ❑ Well Diameter Sealing Material Itop 50') V Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments n PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rubs 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, 1 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, I shall employ persons subject to workman's compensa- tion laws of California." The applic4Yant m c II for all requ Inspections. Complete drawing on reverse side. //��//�7 �O Signed K.y Title: �f��H'tL e_ it - Date: FOR DEPARTMENT USE ONLY Application Accepted by Datao`3 A e p GA Pit orrout nspection b Date 3� Final Inspection by DatTJ Rditional Comments: `CT , Stk 4666781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 895-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 K If FEE AMOUNT DUE AMOUNT REMITTEDkSH RECEIVED BY DATE PERMIT NO. INFO . EH 13-24(REV.11x51 �..i�/ '�� K- a-1Z/ /�'�✓ � — .r su 1w r