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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROMDATEISSUED (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 Ordinanc No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. n .r Job Address City Lot Size . -+ 2 PM 's Name Owner �'�f Address_ x Phone Contractor ress 1.] `S ` , License No Phone / .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-E] E DESTRUCTION ❑ PUMP INSTALLATION"0 SYSTEM RE7,tEl OTHER ❑ DISTANCE TO NEAREST: SEPTICTANK SEWER LINES �DI'SPOSAL FLD. PROP. LINE i FOUNDATION GRICULTURE WE � OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE AREA C STRUCTION SPECIFICATIONS ❑ Industrial— ❑ Open Bottom ❑ Mantec ia. of Well-Excavation —Dia4of Well Casing r 4 ❑ Domestic/Private ❑ Gravel Pack ' ❑ Tracy Type of Casing r �' Specifications M Public - 1-1 Other 4� #t Cl Delta Depth of Grout Seal - Type of Grout I 1 Irrigation —.Approx. Depth 3 l I Eas _rn Surface Seal`lnstall; by I Repair Work Done ❑ Type of Pump ;` ,,..H.P. r. State-Work Done Well'Destruction O ' Well Diameter material Itop 501 t Depth _ "Filler Material (Below 50') —---; O TYPE OF SEPTIC WORK: NEW INSTALy4TION I REPAIR?ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms—� j 6 p 0 Character of soil to a depth of 3 feet: .0 a onff` . Water table depth SEPTIC TANK ❑' Type/Mfg Capacity f��No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of sposal I Distance to nearest: Well �� Foundation Property Line__ LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED ❑ Distance to nearest: Well A— Foundation Property Line r SEEPAGE PITS I 1 Depth 2 S Size �' f` 1�Number ' ! SUMPS L� Distance to nearest: Well Foundation Lu-SJ Property Line DISPOSAL PONDS ❑ ' , r I hereby certify that i have prepared this applicationand that the work will ba done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di$trict. 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, 1 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 applicanh must call for a squired inspections. Complete drawing on reverse side. -»r:-_ Signed X Title: " Date: + FOR DEPARTMENT USE ONLY 1 Application Accepted by Datef Area Pit or Grout Inspection by Date Final Inspection by Date �7 i' • i Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to:,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE4 INFO AMOUNT DUE AMOUNT REMITTED CCK 0 RECEIVED 9Y DATE PERMIT•NO. +.EH 1324 1REV.r/H 5f EH 14 26 y k