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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7'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 (,2 015, City Lot Size, PM r i Owner's Name �� 1 Jt(�>1 Cj0u� Address r. �o �1Q 5�QY_ 1 IZ Phone Centracio Address 1 a&2 � License No.- 2,(Q....,Phone. ( —S�Q TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT 1l DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ 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 i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack C.Tracy Type of Casing Specifications I'1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _. I i Irrigation Approx. Depth I ] Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ t a . Well Destruction ❑ Well Diameter Sealing Material (top 501 , Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION I] DESTRUCTION 1`1 INo septic-syst6n permitted if public sewer is i available within 200 feet.) Installation will serve: Residence Commercial Other —Number of living units:--- —Numbervo rao ?— — Character of soil to a depth of 3 feet: Water table depth e l SEPTIC TANK IJ' Type/Mfg d Capacty ��. No. Compartments . PKG. TREATMENT PLT. ❑ , y r E Method of Disposal Distance to nearest: Well %50 Foundation _._._._._ Property Line LEACHING LINE Pl"-No. & Length of lines Total length/size XIV( z4r of r FILTER BED ❑ Distance to neare t: Well_t_!W ` .F, d tion — � .-,-- Property Line r SEEPAGE PITS Depth Size- r �' Number SUMPS ❑ Distance to nearest: Well _,.g_—Foundation _..Property Line _ j DISPOSAL PONDS ❑ • 1 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-HealiF 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 I 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 applican st call III Iuired inspections. Complete drawing on rev` a side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date r Area �� k Pit or Grout Inspection by Date Final Inspection by Date/Z' Additional Comments: R. ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 .'t" ❑ Tracy 835-6385 Applicant - Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE r INFO AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY DATE PERMIT*NO. r +.EH 13-24 IREV.i i x sl �C1.(] t} er EH 14-2 ''7( 9