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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � _ I k (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.` Job Address l o (c' f S S cn,,. Lot Size I � PM Owner's Name " j V� - Address J contractor S.C,•lam _ Address S�✓>1 � - License No. Phone t TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS P t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ,p,wr+"•"OrOpen`Bottom CI Manteca Dia_ of Well Excavation Dia. of Well Casing f 11 Domestic/Private ❑ Gravel Pack_ C.Tracy Type of Casing Specifications ' l0 Public-1 ❑ Othego� C Delta Depth of Grout Seal _ Type of Grout_.. L Irrigation" ,Approx. Depth ❑ Eastern Surface Seal Installed by _ Repair Work`Done C- Type-af'Pump H.P. State Work Done ,. Well Destruction' ❑ Wel! Diameter. Sealing Material{top 501} Depth G`1 _ Filler Material (Below 5(Y) _ — TYPE OF SEPTIC WORK: NEWANSTALLATION ❑ REPAIR/ADDITION DESTRUCTION El (No septic system permitted it public sewer is available within 200 feet.) t Installation will serve: Residence Commercia rOther V Number of living units: __ Number of bedrooms V Character of soil to a' depth~of 3 feei"'"`"�" "' +� Water table depth SEPTIC TANK ❑ Type/MfgISTl ("+- �"�~ Capacity zz� No. Compartments 2- rr PKG. TREATMENT PLT. C �, Method of Disposal W Distan a tonearest: Well_�� Foundation �� Property Line.__. A LEACHING LINE NNo 8i Length of lines sA97 Total length/size l y FILTER BEDDistaannca"to nearest: Well Foundation--_ Property Line %,rSEEPAGE PITS Q Depth } Size _ Number SUMPS ED .Distance to nearest: Well Foundation Property Line }- �� DISPOSAL PONDS {❑; r ' -"hereby certify that I neve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state law$, and -rules and regulations of! !San Joaquin,Locel Health District. 1 I ;J-.lome 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 shah 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: "1 certify,%tjin tit--performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." vac IVA } ,rThe applicant ru t call for all requl I�a tons. Complete drawing on reverse side. i ,Q �� w Signed xf/'f Z � ^-� 1 Title: 'I !�r�! Date: FOR DEPARTMENT USE ONLY Application Accepted y - ` Date Area r /° Pit or Grout Inspecti by ,DJate Final Inspection by , Additional Comments. Dca11 leanfi 1111 c«mDGl� lYJ p4 11 ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 83646385 r # Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA§M1 INFO AMOUNT DUE AMOUNT REMITTED RECErVED BY DATE PERMIT'NO. +.EHt3-24IREV.ti a 51EH 1s-zs