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APPLICATION FOR PERMIT SAN JOAQUINI LOCAL HEALTH DISTRICT 1601 E. HAZELT ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES I1 YEAR FROM DATE ISSUED (Cor I plete 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 `S07 d City S77e,- Lot Size �X �G`� PM Owner's Name 4945Address Phone y, Y AAE�� 7— License No. ?iS�7�7� Phone 64^35'7 Contractor�G4 ,D - A �J� Address �_,� TYPE OF WELL/PUMP: NEW WELL_❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C3 �Ir SYSTEM REPAIR❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 'F FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS aS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k' - ❑ Industrial ❑ Open Bottom ❑ Manteca' " Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy , ! ,c Type of Casing Specifications 71 Public ❑ Other ❑ Delta �.�1 �Depth of Grout Seat Type of Grout — 1 1 Irrigation —.-Approx. Depth I I Eastern j Surface Seal Installed by _ Repair Work Done L7 Type of Pump H.P. Ir State Work Done Well Destruction LJWell Diameter Sealing Material (top 50') ! 173Depth Filler Material 18elow 50'1 TYPE OF SEPTIC WORK: NEW 11\1 ALN I 1 REPAIR/AQOITION LI DESTRUCTIO (No septic system permitted if public sewer is .available within 200 feet.) Installation will serve: Residence_ Commerciale. Other { �t Number of living units: Number of bedrooms 1t t t Character of soil to a depth of 3 feet: .� Water table depth O SEPTIC TANK 71 Type/Mfg i ----.Capacity--- ` � No. Compartments \` } PKG. TREATMENT PLT. ❑ ,° Method of Disposal \ Distance to nearest: Well I Foundation Property Line p n LEACHING LINE ❑ No. & Length of lines ' Total length/size ! FILTER BED ❑ Distance to nearest: Well i "Foundation I Property Line 7 SEEPAGE PITS 11 Depth t Size I Number SUMPS L] Distance to nearest: Well Foundation t Property Line DISPOSAL PONDS ❑ """"`"'"'""p"e "r° 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, t shall not 4. employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies tho 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," i' The applicant must call for all required ins tions._Complete.draAing.on reverse_side...,,.__,,;, X I� g Title: �� _. Date: /VSine /V FOR DEPARTMENT USE ONLY L Application Accepted by Date rJ it Pit or Grout Inspection b Date lilt Final Inspection by Date "'S2 Additional Comments: II ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca' 823-7104 ❑ Tracy 935-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II I. FEE CK 4 INFO AMOUNT DUE AMOUNT REMITTED I� CASH RECEIVED BY DATE PERMIT-IVO. r E _��V �~ J� �� D �, l� + EH 13-24(REV.r i H slH 14-29 IM