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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZEL T ON AVE., STOCKTON, CA i .. Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED r (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. F / Job Address C� 1-� Ci Lot Size ldll PM k / Owner's Name Address Phone Y Contractor z I _Address License Na.? O) ,7;2' -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ e 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 p Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other i C] Delta Depth of Grout Seal Type of Grout _ i I Irrigation --Approx. Depth 1,1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IQ,"REPAIR/ADDITION IJ DESTRUCTION [ ) INo septic system permitted it public sewer is p 1 +f available within 200 feet.I Installation will serve: Residence Commercial_ ther �f ° Number of living units: Nu mber of b§drooms '4 f Character of soil to a depth of 3 feet: `� u � Water table depth Q SEPTIC TANK ❑ Type/Mfg -4C Capacity'_ 16,01-1 No. Compartments Z PKG. TREATMENT PLT.❑ »k Method of Disposal O _.•. _,. 3 Distance to nearest: Welf" _foundation f ) -,.Property.Line LEACHING LINE L`t--No. & Length of linesc Total length/size FILTER BED ❑ Distance to nearest: Well-R6 til—---Foundation -___-- Property Line t ; SEEPAGE PITS lvi- Depth �� t Sue Number 13 SUMPS ❑ Distance to nearest: Well-&W Foundation //d� Property Line d f DISPOSAL PONDS ❑ l ' 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 Diltrict. 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 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 applicant must call tot II required inspections. Complete drawing onVverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date�� Area it r Grout Inspection by ate 2 inal Inspection by'T/� -4e7 7r 4044Date 24 Additional Comments: r 2 �� 2 r K �� 267 ❑ Stk A6G 6781 ❑ Lodi 3f>9-3 1 ❑ Manteca 823 71 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,, CSA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 9Y DATE PERMIT'NO. INFO +.EH13-24(REV,rikSj A--T3 i EH 14 2a