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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �r� I 1/lJ \l L V City -'z�G G oSize PM Owner's Name e� lY ht +IT Address 1._ `��j�"._. �/� Phone Contractor �Alf- TYPE i l�1 �Address U� License 140. Phone J TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT.❑`l DESTRUCTION'C] - - } 'PUMP INSTALLATION❑ ' _ SYSTEM REPAIR D OTHER ❑ F 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigatjon` — Approx. Depth I ) Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter `` Seating Material Itop 509 Depth ._. f Filler Material (Below 501 D TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION 11 1 N septic system permitted if public:sewer is �1 available within 200 feet.) Installation]will serve: Residence Commercial___"_ Other Number of living units: J_ Number of bedrooms � J I Character of soil to a depth of 3 feet:- -=- Pt rl-t�(�/r1 Water table depth SEPTIC TANK C?"TypelMfgC CG10' e_ 4L Capacity-. 6 No. Compartments PKG. TREATMENT PLT. ❑ f / Method of Disposal 1 Distance to nearest: Well �6D Foundation Property,Line • I LEACHING LINE IGI No. & Length of tines -- —•.- al-length/size FILTER BED] ❑ Distance to nearest: Well-tau— Foundations• w Property Line _ SEEPAGE PITS i I Depth Size } r Number • SUMPS Ll 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 shalt 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 c for all r uir inspections. Gomplete drawing.on rev se side. f Signed Title: _ a Date: FOR DEPARTMENT USE ONLY.: Application Accepted by Date � ,Area ' Pit or Grout Inspection by Date Final Inspection by Date►`--Z.0-"s 4 , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 0 Manteca 823-7104 0 Tracy 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20M, Stk., CA 95201FEE g INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. ! +.EH13-24 iREV,I i H 6 EH t4-28 ! a [3U 3 _1