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f Y ��1 'ky1MpF, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1 1601 E. HAZEL T ON AVE., STOCKTON, CA /f Telephone (209) 466-6781 f PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 " � Qity Lt �STie PM Owner's Nam a �` ddiss ! Confracto d p s 5�0� License�YPhone TYPE OF WELL/PUMP:L NCW 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca -;Dia, of:Well,Excavation Dia. of Well Casing ❑ Domestic/Private . ❑-Gravel Pack; .. ❑.Tracy- 33 ,Type,of Casing .>Specifications. Y ['l Public ❑ Otl4er ❑ Delta Depth of Grout Seal Type of Grout _ ! I Irrigation —Approx. Dep�lRl Eastern 1 Surface Seal Installed by Repair Work Done ❑ Type pf Pump " H.P. 1 State Work Done Weil Destruction ❑ Well Diameter Sealing-Material (top 501 Depth """""Fille"r Material (Below 50') -- - - TYPE OF SEPTIC WORK:. NEW INSTALLATION I1 REPAIR/ADDITION 1.I DESTRUCTION (No septic system permitted if public sewer is f available within 200 feet.) 11 Installation will serve: Residence— Commercial_ Other r y 'Number of living units: Number of bedrooms Character of soil to a depth of-3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg r .Capacity No. Compartments µ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Propdrty Line: F _ LEACHING LINE ❑ No. & Length of lines '41 _ Total length/size `5 FILTER BED ❑ Distance to nearest: Well .Foundation` Property Line SEEPAGE PITS I I Depth Size Number < SUMPS' D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ R . I hereby certify that I have prepared this application and that the work will be,done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health District. r Homeowner 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 issued,I shall employ persons subject to workman's compensa- tion laws oiLCalifornia." 41 The applicant must call for all required inspections. Complete drawing on reverse side. t Title: T—� Dat e50'_f ' FOR DEPARTMENT USE ONLY Application Accepted by ^ Date Aram I n /4 Pit or Grout Inspection by DateFin I inspection.by = y Date - - : Additional Comments: _:d, r ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ 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 AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. INFO (n ' r.EH13-24{REV.I/Hsi r011 n L.� EH 14-26 LL L.L 1