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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 9 (Complete in Triplicate) ..:,,` ` .,-•`'. ;;�"; a't•,'; ,, ,, "• a 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address /,4 1 " City Lot Sizf]ePM Owner's Name r' i Address t _--.--- , - Phone- _ .. t `Contractor� �'• � r i Address" Y ` License No." iPhone > TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO N.EARES, ,SEPTIC:TANI( SEWER LINES DISPOSAL FLD, PROP: LINE FOUNDATIONAGRICULTURE WELL ;�Tf OTHER°WELL ""PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f Specifications i 17 Public ❑ Other 1 ❑ Delta Depth of GrouttSeal Type of Grout ❑ Irrigation ---Approx. Depth EJEastern Surface Seal 614alled by Repair Work Done ❑ Type of Pump H,P. State Work Done I . Well Destruction ❑ Well-N meter �{ Sealing Material (top Depth Filler Material (Below50')" . ! TYPE OF SEPTIC WORK:' NEW:INSTALLATION.,-• REPAIR/,ADDITION [J—DESTRUCTION ❑ INa septic system"permitted if public sewer is availablelwi®rn 200 feet.) a InstaHation_wiil serve: Residence"_CommercialOther Number of living units: j —Number of bedrooms ti 3 Character of soil to a depth of 3 feet: f ' r} " ' ' Water table f ` i SEPTIC TANK Type/Mfg j L depth Capacity No. Compartments PKG. TREATMENT PLT ❑ 1 C— t Method of Disposat (%: ,. Distance t nearest: Well 1� Foundation 1 .1., 'T', — 0 r - _:,Property Line 'b : LEACHING LINE No. & Length of lines d Total I th/size GZd i FILTER BEDrW"Distance to nearest: Well wv_ Foundation,'`�If� Prop" Lin # SEEPAGE PITS ❑A Depth " Size ` ,{:r~ ! , i r F Number t SUMPS ❑+ Distance to nearest: Well �Fo_undation DISPOSAL PONDS ❑ ' kk Property Line f 1 hereby certify that I have prepared this application and that the work will.be done in accordance with San Joaquin countyordinances, state l , and rules and regulations of the'San Joaquin Local Health District. laws f E ' Home owrier or licensed agent's signature cekifies the followin i l cern ` that in`the"performance of the work for which this permit:is issued, I she)!n j employ an 1 g V- D V S p Y Y persor rn such manner as to became subject to workman's confpensationdaws of California."Contractor's hiring or sub-contracting signature- certifies the following:_966ertify that in the performance of the work for which this permit is issued,i shall employ to workman's compensa- tion laws of California." 4 # y prsons subject , The applicant must call�f all quired inspections. Complete drawing on reverse side. j Signed s` t " X .fig. Title: Date: _��. ,•Ati F9R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by } Date Final.Inspection by Date �r` f Additions! Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621' } ❑ Manteca 823-7104 ❑ Tracy 835 6385 =S Applicant- Return'all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k„ CA 95201 r 7 FEE AMOUNT DUE I AMOUNT REMITTED CK ! ; -INFO _ - Y. CASH RECEIVED BY_ DATE �PERMIT`NO. ,. H13-24 4REV.1/B 5) `'7 1 �J1