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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. ! Job Address / Lot Size PM yb-o 333- i1s� Owner's Name I -A.0 Address 5 Phone F r Contractor Address License No. Phone TYPE OF WV/PUMP: NEW WELL ❑ WELL REPL MENT © DESTRUCTION ❑ PUMP INSTALLATION ❑ SY M REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER L S DISPOSAL FLD. PROP. LINE FOUNDATION AG LTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PRO M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation pprox. Depth l I Eastern Surface Seal Installed by Repair Work Done ype of Pump H.P. State Work Done Well Destructio ❑ Well Diameter .- Sealing Material {top 50'1 Depth Filler Material (Below 50') _ TYPE F SFPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation wilt serve: Residence— Commercial_ Other arty r Number of living units: Number of Vedrooms.. Character of soil to a depth of 3 feet:' Water table depth LJT SEPTIC TANK Type/Mfg a Capacity AW No. Compartments 3 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 1670 Foundation j b + Property Line— 5-.' LEACHING LINE No. & Length of lines 0 Total length/size 14,0 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size �q. Number l SUMPS ❑ Distance.to neare t: Well Foundation�_ 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 Dt%trict. 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 all for all required insRpections. Complete drawing on rev-trse side. Signed X Title: Date: _ FOR DEPART ENT USE ONLY,,—'-' Application Accepted In � Date Arae Pit or Grout Inspection by Date Final Inspection by Date/ r 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 13-24{REV. /n 51 EH 14-28 ��