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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E�-H,AZE.LTON AVE., STOCKTON, CA TelephoneV(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 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 1 v�/ /Ao r QZ Cit Size PM Owner's Name Y' ddress l �1 �! (� �_ a Phone Contractor Address � O'!�_ ! 1License No. 11023 Phone S" L TYPE OF WELL/PUMP: NEW:WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION"El" _PUMP INSTALLATION 1-1SYSTEMREPAIR ! OTHER El 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 Type of Casing"'"---- Y Specifications l7 Public (❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ I i Irrigation Approx. Depth` I } stern Surface Seal Installed by Repair Work Dane [K Type of Pump J k H.P. State Work Done . — f Well Destruction ❑ Well Diameter Sealing Material (top 50') T r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f'] REPAIR/ADDITION l I DESTRUCTION I'LIt.septic system permitted if public sewer is i available within 200 feet./ ;.v 1r .tallation•will serve: Residence___,_ Commercial_ Other f 4 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _� u` —��_ p Water table depth SEPTIC TANK ❑ Type/Mfg — Capacity No.Cpmpartments "" �. \ "A S : i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well foundation Property Line 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 ❑ Distance to nearest: Well Foundation Property`Line�—t — , -- 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 regulat an Joaquin Local Health Di§trict. Home own, r licensed agent signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not employ a person in such man r as to becom, ub-ect t orkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies a followin : "I certif at in the perfo a c e work for which ' permit is issued, l shall employ persons subject to workman's compensa- tion la sof ca" a." The ap licant m or requir in mpl a drawing on rev e. Signed Title: r Date: O y OR DEPARTMENT USE ONLY Application Accepted by Date /-i- Area Pit or Grout Inspection by Date Final Inspection by_� .� � _ Date 1-11)-►CP Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Perrnit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ♦ EH13-24(REV.rind �� EH 14-26 -`�