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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. /_ /r /� /� .� Job Address City Lot Size 2 y J S ( zt-A, PM ? ✓ &I& �/I Phone 6 `/— 0! Owner's Name,_, Address j r Contractor Address / �Gt�!/C.!'Yl License No. ia" Phone 7 d_"ZZ 1,--TYPEbFWEL1%PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ C` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ `.. 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ` ❑ Irrigation ---Approx. Depth ❑ 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 REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nose tics stem f _ p y 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 Z(10 No. Compartments \ e^ PKG. TREATMENT PLT. ❑ Method of Dispo ` Distance to nearest: Well Foundation ,Property Line LEACHING LINE No. b Length of lines �,r.T/gt,,aCl length/size FILTER BED ❑ Distance to nearest: Well/Gw7 Foundation 2V._ Property Line -195 SEEPAGE PITS ❑ Depth 2_57 Size 3 3 /Number 2 SUMPS ❑ Distance to nearest: Well Foundation �UD 4 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 county ordinances, state laws, and rules and regulatiells-Qf 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 menner 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 applicarh must'call for I required inspections. Complete drawing on reverse side. C� Signed % Title: C/�� Date: ! — 3 (/ DEPARTMENT USE ONLY T Application Accepted by 1`Q6 - �,.._.. Date —��13 Area 0 Pit or Grout Inspection by Mzjftp Date 9-640-•Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BV Q DATE PERMIT NO.. 1EH1124IREv.1/R51 -7,-3, d.1. _ •/3`� "1 Vqp EH 11-28