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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone !2091 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 Rules and Regulations of the San Joaquin Local Wealth +D�istri+c�t. Z73/ , 27 3-3 �273,�, ; ` Job Address Z 7 S__1 City Lot Size,k a 243 Pm 2 22 �! L. 7. � �o Phone Owner's Name Address Contractor's Nam & rte ' License No. 2 7 �` 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 PROBLEM-AREA CONSTRUCTION SPECIFICATIONS 4`\ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other j O Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump, H.P. State Work Done Well Destruction ❑ Well DiameterSealing Material (top 50') b. Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is �( c available within 200 feet.) Installation will serve: Residence!` : Commercial Other Number of living units: Number of bedrooms` 1 Character of soil to a depth of 3 feet:: 6� Water table depth SEPTIC TANK Type/Mfg /3,,4� Capacity !/CsY No. Compartments PKG. TREATMENT PLT. ❑ 'I ' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines -.r Total length/size 1 1 FILTER BED ❑ Distance to nearest: —Well Foundation Property Line I .-. SEEPAGE PITS ❑ Depth I r '—Size Number ; SUMPS ❑ Distance to nearest:. Well Foundation Property Line DISPOSAL PONDS ❑ I t f 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 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 appl' must call for all req -red inspections. Complete drawing on.reveise side. F Signed Title: "l .'y Anve Date: T.- - _b , ---.,.—,-.FOR DEPARTMENT-USE ONLY—� / Application Ac. c.epted by Date 49 �a� o Area—/ Pit or Grout Inspection by pate. Final Inspection by f_Date ra��1^ J Additional Comments: L.1 1 a G 40 ri.� . r -7,51 > ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant ca 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 FEE AMOUNT DUE ' AMOUNT REMITTED RECEIVED BY DATE PERMWNO. INFO CASH EH 13-24(REV.1018311 O Z EH 14-28 I