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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I 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 .7 AV qv City ��,@� Lot Size PM Owner's Name 46-0Z4 f"/,'Cen .-- - Address Phone 2,r - I Contractor's Name 0 ��"/J'& l(-,�SllAIX License No. 2� —�� Phone" 4 ,O TYPE OF WELL/PUMP_: NEW W.ELL,❑ -__._._-'_,-WELL-REP.LACEMENT❑_.:,;i,, ES.TRU.CTION_❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST::SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNbATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL /-PROBLEM AREA /' CONSTRUCTION SPECIFICATIONS ❑ Industrial z ; ❑ Open Bottom ' C1Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications 0 �.❑ Public 0 Other ❑ D.elta., . Depth of Grout Seal Type of Grout Z ❑Jrrigation ---Approx. Depth ❑'fasten �- Surface Seal Installed by I!r 'Repair Work Done ❑, .Type of Pump H P." State Work Done Well Destructibn ❑ tNall Diameter--- Sealing Material (top 50') 1 Depth - ..Filler Material (Below.509 TYPE OF SEPTIC WORK:'r+NEW INSTALLATION 9 REPAIR/AD1A1T10Ny❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 4 available within 200 feet.) Installation Will see rvet/: Residence_-. Commercial_ Other _�� N*_ . . Number of living units: _/_ Number of bedrooms 7— Character of soil to a depth of 3 feet: `/t Q,�P/% _Water table depth SEPTIC TANK "dCr Type/Mfg /a#RA, f-'N Capaci 6zo 0 No. Compartments PKG:TREATMENT PLT.-F-1 R . � Method,of Djsposal- r Distance to nearest: Well A097 t' Foundation-30_ Property.Line �^ t LEACHING LINE ,__ IH'_.,No. & Length of lines ` ""� j} f }Total length/size -*3-' .� FILTER BED i ❑ Distance to nearest: well (L^p_t—Foundation-fid - �Property Line�^�^�-"'"------^-^- 3 SEEPAGE PITS y❑ 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. . f 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."Contractors hiring or sub-contractin signature certifies the following: - 9 8 "I certify that in the performance of the work for which this permit is issued, I shall employ pers'vns subjecfto workman's compensa- tion laws of California." I The applican call for all reqWd inspections. Complete drawing on reverse side Signed �� -� ; � Title: f Date: ' FDR QEP TMENT USE ONLY i Application Accepted by Date Area Z Pit or Grout Inspection by - Date - <:.Final Inspection by Date V'O Additional Comments: ❑ 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 FEEINFO AMOUNT DUE :kAMOrUUNT REMITTED' ',`CASH RECEIVED By' `_ DATE PERMiT`NO. + EH 13-2 (REV,10/831 Uf EH 14266 l 1"