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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT { 1601 E. HAZELTON ON AVE.; STOCKTON, CA _ Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. I Job Address r `-� 4, f City ��.; Lot Size PM Owner's Name J_OC- 13V'y�?I�+s Address _ Phone lr Contractor f/ioN "JAddressLicense ��Phone' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I e/ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ x A DISTANCE TO NEAREST:SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP. LINE i' ` FOUNQATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ f INTENDED USE TYPE OF WELL— PROBLEM AREA "CONSTRUCTIONSPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel P` ❑ Tracy Type of Casing Specifications � \\\ FPublic ❑ Other '4' ❑ Delta Depth of Grout Seal T Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work-Done -El "Type of-Pump ' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: -NEW INSTALLATIONA REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms -J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ® Type/Mfg _�'rE C_.3sT CClYG. Capacityd� ._� W. Compartments :4 PKG. TREATMENT PLT. ❑ Method of Di Y Distance to nearest: Well 0 ` 0 Disposal _ Foundation �._�_Property Line �✓� ` ' LEACHING LINE 11 No. & Length of lines r 1001 I _ Total length/size DQ FILTER BED _ .;, ❑ Distance to:nearest: Well P00 ° Foundation /5° Property Line SEEPAGE PITS l I Depth l.y' _Size-ZX 152' Number.W X SUMPS Y_I Distance to nearest: Well too°f Foundation /Y� _ 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 j 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 applicant mu call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: ��'7"g/ t � t IR DEP RTMENT••USE-ONLY --��- - Application Accepted by Date Pit or Grout Inspection by Data Final Inspection by Date 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, Silk., CA 95201 FEE f INFO AMOUNT DUE AMOUNT REMITTED CK CASH /R�EECCEIVED BY DATE PERMIT'No. + EM 124(REV.t/x51 'i t' EH 14- ID4-za J //'.vim o(tJ I 1 ff rA4 --.