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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 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 Rules and Regulations of the San Joaquin Local Health District. /J Job Address /,37,?//V, "� City Lot Size PM Owner's Na ' Address ,e Phone CT Contracto Address )OV, AOY747 License No.,�7O 7Z G Phone �p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMM NT ❑ 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 M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout --- I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H-P. State Work Done _ Well Destruction ❑ Wel! Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION IP<R PAIRIA ITION t I DESTRUCTION i I (No septic system permitted it public sewer is available within 200 feet.) ✓ ti Installation will serve: Residence_ Commer rai� Ot er Number of living units: -�! Number of edrooms / Character of soil to a depth of 3 feet: - Water table depth f S15PTIC TANK 1 Type/Mfg Capacity/ r�0_ No. Compartments z PKG. TREATMENT PLT.. ❑ �. Method of Disposal Distance to nearest: Well %�:M _ Foundation d!22 Property Line f LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation=- Property Line SEEPAGE PITS IX Depth Size f Number i SUMPS 0 Distance to nearest: Well Foundation..A0.___.._-_ 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 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." 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 shalt employ persons subject to workman's compensa- tion laws of California." The applicant ust call f II r wired inspections. Complete drawing on revers¢s da: Signed Title: ,�// Date46 FOR DEPARTMENT USE ONLY Application Accepted by Date ''� `r Area it r Grout Inspection by ginaI Inspection by Datt6�� 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 20W, Stk., CA 85201FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'HO. EH 3-24 4REV.i/a51 EH 14-2e �/� �s'�-t,oL3