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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - 1601 E. HAZE T ON 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. J� R Y Cit Lot Sizes PM Job Address Y O,MwFd0 _ Owner's Names ��C Address HST Phone Contractor_ � l�'Cia� Address /� License No. ?� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 1'7 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigation _.Approx. Depth ( I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Q Well Diameter Sealing Material /top 501 Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I ) INo septic system permitteo if public sewer is W available within 200 feet.) Installation will serve: Residence commercial— Other C Number of living units: _/__ Number of bedrooms Character of soil to a depth of 3 feet: AVOAE Water table depth SEPTIC TANK ❑ Type/Mfg p+ 4, CapacitydQ J.No. Compartments PKG. TREATMENT PLT. ❑ �--�-- - )e7~ Method of%l LW-' Distance to nearest: Well Foundation Property line __ LEACHING LINEpe "No. & Length of tines C d tTotal length/size / F� FILTER BED ❑ Distance to nearest: Well��rFoundation_ Property Line 00v rr-- SEEPAGE PITS l I Depth Size Number SUMPS Distance to nearest: W611./66 Foundation Q .F Property Line 1T 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 taws, an rules and regulations of the San Joaquin Local Health Di-Mrict. Home owner or licensed agent's signature certifies the following: "l 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 taws of California." The applicant must call for II requ'ed inspections. Complete drawing on reverse side. Signed X Title: ��ec&_C < Date: ' FOR DEPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout Inspection by Date Final Inspection by to Additional Comments: a ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 8217104 ❑ Tracy 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 FEE INFO AMOUNT DUE AMOUNT REMITTED tCK81F RECEIVED BY411 DATE PERMIT'NO. + E rs-24IR .i i n51 Q.00 Eli 11-28