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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.M9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ��qq Job Address W o W Od C� Crty 't en Lot Size OC ;r QPM 1" �� (� �gg Owner's Name _ _ ry rrcCAddress 2ff L S�,U}[DLt (`, Phan. i Q—3 -7 J Contractor's Namett L, U1Cw�li_17r'- `�c _ Lihense No. Phone TYPE OF WELL/PUMP: NEW,WELL El, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �-1' ' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 2 0 �� SEWER LINES 0O DISPOSAL FLD. PROP. LINE FOUNDATION qQ't' AGRICULTURE WELL N OTHER WELL PITS/SUMPS I TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ] firial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing 'r Id Domestic/Private 0.Gravel Pack ❑ Tracy Type of Casing -1 f :c Specifications -011LII� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 4 pt�pprox. Depth ❑ Eastern Surface Seat installed by ri Repair Work Done ❑ Type of Pump �,r H.P. State Work Done Well Destruction ❑ Well Dianieter Sealing Material (top 501 VVV111 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) i Installation will serve:, Residence_` Commercial_ Other Number of living units: / Number of bedrooms ` Character of soil toa depth of 3 feet: 4 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Pro . � - party Line'' - 1 LEACHING LINE ❑ No_ & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: ,^Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation_ 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 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 California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is isaued, I shall employ persons subject to workman's compense- tion laws of California." The applica must freq Ired inspections. Complete drawing on reverse side. Signed X ! '-' Title: � r J Data: R D A M SE ONLY Application Accepted byDate Awa Q 3 Pit or Grout Inspe o y Date incl Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835— Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO CASH 1 / +EH 13-24(REV.10/831 Y Jt` 4 T I I" '1 (� �"Io EH 14-28 UU�1 L! (J o�