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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) 1 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. n Job Address i!G! City Lot Size�(J��—rQ� PM Owner's Namel tZrP�1 _�-� - Address �^��,�� • `?ca1apo — Acamm Phone Contractor @S +C Address .Q 0 677" dr _ License No. Q:R_!�Z Phone 3� `sly TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r V DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 'PROP. LINE FOUNDATION AGRICULTURF WELL ,OTHER WELL PITS/SUMPS n INTENDED USE TYPE OF WELL PROBLEMiAREAXCONSTROCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I t"1 Public f_1 Other ❑ Delta Depth of Grout Seal Type of Grout N j I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Dohe ❑ Type of Pump H.P. State Work Done Well Destruction © Well Diameter Sealing Material (top 50') Depth 2' Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION . REPAIR/ADDITION l-I DESTRUCTION 1.1 (No septic system permitted if public sewer is Installation will serve: Residence"� Commercial available within 200 feet.) Other -.- - a Number of living units: Number.of bedrooms. f ff Character of soil to a depth of 3 feet: Ha 0sw-) '�' i Water table depth rot 0 i SEPTIC TANK TypelMfgr ` C rllie5 ' Capacity [(000 No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation r 0 Property Line LEACHING LINE IV No. & Length of lines 5"-U01� f Total length/size ! ./ FILTER BED ❑ Distance to nearest: Well_qc) ! Foundation rQ Property Line t SEEPAGE PITS IV Depth 6115y Size-_=—s]s��' ' —1 — Nurnber— — A s SUMPS ❑ Distance to nearest, WellI QQ Foundation1 C} Property i ine 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, l 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,-1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for qui d inspections. Complete drawing on reverse side P k Signed X Title: - Date: FOR DEP RTMENT USE ONLY f Application Accepted by Date Ar or Grout Inspection by Date f"u Final Inspection by � Date Additional Comments: ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 tt Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY t. DATE PERMIYNO. INFO + EH 1324IREV.iiHsf / EH 14-26