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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .s. (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 `J ( City. , Lot Size PM Owner's Name, Address Phone Contract Address!°L! s 11�'�fO ! X&e4 License No.J ' D z Z '- Ph,,,:?&t `1 [ a TYPE OF WELL/PUMP: NEW WELL ❑ 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSr ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ---Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ^ 1` w ? a '` State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION t'1 REPAI ADDITIO DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re ; ante Commercial_ O he Number of living units: Number of droorn Character of soil to a depth of 3 feefl. ✓l+ti Water table depth D SEPTIC TANK ❑ iType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ :_ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE "53, No. & Length of lines Totahlength/size FILTER BED ❑ Distance to nearest: Well Foundation Property�Line_ SEEPAGE PITS Depth i Size Number k, SUMPS ❑ Distance io nearest: Well _/ fes Foundation /D Property Line DISPOSAL PONDS: °t.' O. t.W e •, �5 -4 _ - I hereby certify that t 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 tocaE Health Dibtrict. �� 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." Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work foe which this permit is issued, I shall employ persons subject'to Work man's.compensa- tion laws of California." p f The applicant t call for all r fired ' spections. Complete drawing on reverse 'id ' Signed X Title: Date: F f � FOR DEPARTMENT USE ONLY L l f r Application Accepted by Dated Area to or Grout Inspection by DateFinal Inspection by i at,I Ar j Additional Comments: } ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385• Applicant- Return all copies to: Environmental Health PermitYServices 1601 E. Hazelton Ave.., P.O. Box 2009, Stk.,CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT-NO. +. E"1 13-24(REV. EH 14-26