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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T 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/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 Ryles and Regulations of the San Joaquin Local Health District. t, Job Address ` 9 Ud� �% t City .9 / Lot Size f! PM r +�LL'/ Owner's Name _ 7 Ie 66 C-1 Address / 7 Z.AeAZ o6fi&&O Phone Contract r Address 40, License No. raJ�6—Phone TYPE Or 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done V Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—if!-"Commercial_ Other'} Number of living units: —I— Number of bedrooms Character of soil to a depth of 3 feet: /J •�� - ��, Water table depth SEPTIC TANK E] Type/Mfg 1��fi Capacity�(� No. Compartments PKG. TREATMENT PLT. ❑ �.� Method of Disposal Distance to nearest: ] Well., Foundation IqO Property Line - O LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance_to-nearest: Well Foundation.- Property Line SEEPAGE PITS fl Depth /O F 7 Size 1 Number 1;Z SUMPS 5 10 Distance to nearest: Well cift Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordirlances, state laws, and _✓' rules and regulations of the San,Joaquin Local Health District. I i - ' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of t6'e work fol 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-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 must call$or re insopec�tions.. Complete drawing on reverse side., v / Signed �.�"� - Title: 1 Date: l VIDEPARTMENT USE ONLY Application Accepted by Date/�_ 7 Area Pit or Grout Inspection by Date Final Inspection by l� 4 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, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED" CASH RECEIVED BY- DATE PERMIT'NO. +EH 13-24MEV.1/851 5-00 IZ30-fs V—/5(hI EH 1426 a