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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1370 ��" /S �f t Cih' Lot Size PM Owner's Address ©7 /6 Phond% 6 —764?.3 Cont2 00eAddress � L �/ License N ?T Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _IM-17 SEWER LINES 100-717 DISPOSAL FLD. PROP. LINE # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r. Y I,NTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D IIndu�strial ff Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing R;-B6mestic/Private E7 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public LJOther Ll Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. DRh D Eastern Surface Seal-Installed by! Repair Work Done. ❑ Type of Pum p� - 1 yp H•P•-- �, ""' State Work Done '} Well Destruction)A ❑"= 1Ne(L Diameter Sealing Material (top 50'I ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK;. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO septic system permitted H public sewer is _ f available within 200 feet•I_ f Installation will serve: Residence t Commercial Other Number of living units: Number of bedrooms g j Character of soil to a depth of 3 feet: t } ; s Water table depth \ SEPTIC TANK" C1 Type/Mfg) ' Capacity No. Compartments PKG. TREATMENT PLT: ❑ �f 1 } j Method of Disposal 4 Distance to nearest: Well' r" Foundation Property Line i LEACHING LINE "" ❑• _ No. & Length of lines f Total length/size / FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 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 I certifies the fo wing: "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 al ornia."" 1. f The applic m call for II squired i s ions. C mplete drawing a rse side. Signed Title: Date: OR DEPARTMENT USE ONLY / Application Accepted by Date /,X -i x Cly- / r� Area Pit or Grout Inspection by Date Final Inspection by rr �2 �_„Date Additional Comments: —7 © 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 FEE AMOUNT DUE AMOUNT REMITTED CK INFO �7 CASH RECEIVED By DATE PERMIT'NO. + EH124IREV.t/a5S EH 1120