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t s. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA . Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (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 Ordiranc/e No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 44je.5f 4e lee- L Job Address Suf/ / City K Lot Size PM �y�x3 CB•y4tjrgviki N'�S � � f _ r Owner's Name Q� to Address rLC� A 4 Phone 0'0,75 E. My I-He .Sr Contractor ddress -S �� - License No. S e� Phone 9� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [I DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER�" ��ofq�01Y�arrg DISTANCE TON ST: 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 L] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public I �Olne 11 Delta Depth of Grout Seal Type of Grout--- I I Irrigation i 'e©.A�o�T. Depth I 1 Eastern Surface Seal Installed by Repair Work Donee ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 50'1 — k I Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1.1 DESTRUCTION ! I (No septic system permitted if public sewer is 1 available within 200 feet.) Installation,w II serve: Residence_ Commercial_ Other i I n Number of living units: Number of bedrooms Character of?soil to a depth of 3 feet: Water table depth !� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Q Distance to nearest: Well Foundation Property Line V VI LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ti 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 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 Californi ." The applicant m all r all requir d i s mplete drawing on r se side. Signed X Title: r$, L t ell Date: FOR DEPARTMENT USE ONLY _ Application Accepted by Date Area ' Date Pit or Grout Inspection by Date Final Inspection by G Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 El 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 CK U RECEIVED BY DATE PERMIT NO. INFO 71 +.EH 13-24 IREV.3/w 51 r& 1EH 11-21 i -