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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 City Lot Size/r� iCf�G PM w Owner's Name �/�� y / Z2C[T Address Phone r /? N Contractor's Name /J .a© ,6eAW e J dlll'.f License No. 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 —0-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— E Well,Destruction ..s ❑ Well Diameter Sealing MaterpJ_(top_M]_ ?`r • : Depth Filler Material (Below 50') .TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic-system-permitted if public sewer is 1. { available within 200 feet.) Installation will serve: Residence Commercial_ Other ° Number of living units; ` Number of bedrooms !�e — Character of soil to a depth of 3 feet: CL y "' ^ Water table depth SEPTIC TANK I P'-Type/Mfg Capacity f[OD cAL No. Compartments PKG. TREATMENT:P_LT.-❑ *- -_�-�.. �: Method of Disposal 4;4 Distance to nearest: Well A:W Foundation /17 Property Line 1 LEACHING LINE 01-No. & Length of lines 9 Total length/size-__ FILTER ength/size--FILTER BED ❑ Distance to nearest: Well 99 Foundation ZZ) f Property Line S-0 f_ SEEPAGE PITS 9?`eDepth Size__- Number 2 SUMPS ❑ Distance to nearest: Well Z30 I Foundation ' Q Property Line 5� DISPOSAL PONDS ❑ 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." r The.!Opp licant mu call for a!I required ins ctions. omplete drawing on reverse side. Signed Title:_ Date: 1 FOR DEPARTMENT USE ONLY �( /� Application Accepted by Date Area 2—/` Pit or Grout inspection by Date� Final Inspection by �"�� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE A�MruOUNT REMITTED CASH �RECEIVED BY DATE PERMIT NO. + EH 1324(REV.10183) EH 1426