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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 1 . (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 ) /S �. �(1/ �� _ City � OAS Lot Size PM Owner's Name /! gDy Address Phone Contractor y sc.v/G1Address - `*'00,4) License No:A SA'-/90 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 , Y_ ❑Gravel Pack ❑ Tracy Type of Casing Specifications (`I Public ` C1 Other ❑ Delta Depth of Grout Seal Type of Grout _ , I I Irrigation �.-Apprpx. Depth I 1 Eastern Surface Seal Installed by. Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter ;*Sealing Material {top 50') Depth Filler Material (Below 501 __ I TYPE OFSEPTICWORK: NEW INSTALLATION REPAIR/ADDITiON I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) li Installation will serve: Residence's Commercial Other_ Number of living units: --Z— Number of bedrooms Character of soil to a depth of 3 feet: " Water table depth t SEPTIC TANK hf Type/Mfg G t.OJV G/l t, Capacity_.Law No. Compartments . PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well k3ot Foundation cs/.� Property Line �o ^ I LEACHING LINE No.`& Length of lines Total length/size /,7,p FILTER BED ❑ Distance to nearest: Well Aw-y' Foundation Iy dr Property Line �Q SEEPAGE PITS ycl. Depth Ca L- "SizeNumber 3 ~ 2 � SUMPS L1 -Distance to nearest: Well 15?2e Foundation io 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 s 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 i Certifies the following: "I certify that in the performance of the work for which this permit is issued,employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub tion laws of California." contracting signature I shall employ persons subject to workman's cornpensa- nature The applican must call all required inspections. Complete drawing an reverse side. Signed X Title: Date: DEPARTMENT USE ONLY //,�h Application Accepted by Date /" y4 �Q Area Pit or Grout Inspection byDate Final Inspection by Z � Datef Additional Comments: a 5 ❑ Stk . 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEECK 6 INFO AMOUNT DUE MOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13.24 1REV.r/n s1 ® LA 1 i� EH 1426 ) .. _ ! ►Sl�o es- (p