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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON 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/of 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 S>3` vd L e City`. C/ !� Lot Size PM Owner's Name Av� f"oo v Address PedtoX Rd• Phone Contractor Ay�� SO/1" Address Av e^ License No. YWY'"S91 Phone 0-M- yAl t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L1 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f V1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ M Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material /Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION f I DESTRUCTION i I (No.septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence Commercial_ Other M06;J 140MAZ Number of living units: __L— Number of bedrooms �- Character of soil to a depth of 3 feet: L Water table depth r20 SEPTIC TANK JA Type/Mfg P*4- Capacity 200 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 123 '� Foundation �0 ` Property Line i00' LEACHING LINE V No. & Length of lines A " y0 Total length/size I?o FILTER BED ❑ Distance to nearest: Well 1 X S' Foundation IS ' Property Line /00 SEEPAGE PITS I I Depth 100 Size Xf -v&' _ Number a' SUMPS 0 Distance to nearest: Well Foundation y4 ` Property Line 1d0 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 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 mut call for all required inspections. Complete drawing on reverse side. Signed X Title: Data: F-OR DEPARTMENT USE ONLY Application Accepted by L911 Date a rea Pit or Grout Inspection by _ I Date Final Inspection by Date zSr o Additional Comments: no4 IeL, ,F-C -0:;P ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca'823- ❑ Tracy 835-6385 Appficant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO 1l,, RECEIVED 13Y DATE p PERMIT N0. + EH 1�-28(REV,i i h 5) �'l