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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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 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 & jC� Ci Lot Size ! �-VJJ PM Owner's Name 4� Address 3 7(P C�2 �JI...J C Phone Contract +� 77l License No329aa (' Ph,,, f-IT10 S7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ > DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 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 H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material-(top 50') ` Depth Filler Material (Below 501 9 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION El DESTRUCTION Ll (No septic system permitted if public sewer is J ` y / available within 200 feet.) Installation will serve: Residence y Commercial Other Number of living units: Number f edro ms _ Character of soil to a depth of 3 feet: Water table depth Z06 SEPTIC TANK P!I;�'_ Type/Mfg Capacity 1600 No. Compartments PKG. TREATMENT PLT. ❑ ` t Method of Dirosal Distance to nearest: Well 50 Foundation /0 Property Line S LEACHING LINE 12'�No. & Length of lines 3- qO Total length/size Jo FILTER BED ❑ Distance to nearest: Well 520- Foundation—10 Property Line _ ,S cr SEEPAGE PITS C�Depth �� Size � Number 3 SUMPS ❑ Distance to nearest: Well- Foundation /0 F 1 _Property Line 5- 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 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 California." The applica t must call or I required inspections. Complete drawing on`y/ YY_side. Signed Title: P Date: p_ FOR DEPARTMENT USE ONLY r Application Accepted bya 1rni Date-5 a 2-j?.!�77 Area / Pit r Grout Inspection by�t__— ate rFinal Inspection by Dawe 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 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NNO. + EH 13-241REV.1/851 EH 14-26