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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. TMs application is made in compliande 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 Healttigisir; t. Job Address 12V33 dA 5%4 �- _ City XWw�� Lot Size �G PM /� J Owner's Name 4• 36,q YPb yc!;- Address y. 1 ��S ��c Phone Contractorz +� i�iL G� �Address c �y License Na�{✓'15�� Phone TYPE OF WELL/PUMP: NEW 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 i PROBLEM AREA CONSTRUCTION SPECIFICATIONS { ❑ Industrial ❑ Open Bottom j ❑ Manteca Dia.•of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ` Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by. -� Repair Work Done ❑ Type of Pump i H.P. �f State Work Done_ r Well Destruction C1Well Diameter Sealing Material (top 501 LJ�' Depth i Filler Material {Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑- REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is W y available within 200 feet.) c r Installation will serve: Residence C ommercial'— Other � Nurribir of living units: Number of bedrooms �- Character of soil to a depth of 3 feet: Jr �W� 4,r%4K� � Water table depth 121L � l SEPTIC TANK Ix Type/Mfg 1 Capacity /a�Pi C?,} 41o.'Compartments PKG. TREATMENT PLT. ❑ i F T � 'Method of Disposa Distance to nearestW611 Foundation 'Property Line _3- LEACHING LINE ❑ No. & Length of,lines Total length/size �✓ FILTER BED C1Distance to nearest: Well �(7 Foundation drp "7T� Property Line �� 7- SEEPAGE PITS ❑ Depth S,, f �U , Number SUMPS r� Distance to nearest. Well Foundation Property Line DISPOSAL PONDS ❑ i 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,pd'Hormance 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 ,h}? 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." s a The applicant must call for I requ'ed inspections.'Complete drawing on re)erse side. Signed X_ �` Title. Date�.+ r, ... , E y FOR:DEPARTMENT USE ONLY ( s . 1 Application Accepted by Date Area _ it Pit or Grout Inspection by ! Date Final Inspection by rfiDate Additional Comments: { _❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 t Y' � rrM/_,mow. FEE AMOUNT.DUE__ _ .'AMOUNT REMITTED-_. - CK„ _{,. - RECEIVED 6Y DATE P RMIT'NO. - INFO- - CASH % + EH 13-24lREV.i7H5170,12 ��— EH 14-28 r