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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZELTON 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. �crx X /�►f Job Address Tr` City G Lot Size � PM Owner's Name _ ,_ ✓y/V��G+ _- Address Phone ContracVr- 006a-Xd .W. Address re� '0' /!� License No, 5A Phone 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ { 9t 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 - HYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial' 0-Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J❑ Domestic/Private L❑ Gravel Pack ❑ Tracy Type of Casing Specifications I9 Public t F1 Other I.-] 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 ° ❑ Well Diameter Seating Material Itop 50'1 Depth - Filler.Material (Below 501 -4' — TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION [ I (No septic system permitted if public sewer is r - available within 200 feet.) 11\ Installation will serve: 'Residence t Commercial_ Other l Number of living units: —I— Number bf bedrooms 1645"I'acter of soil to a depth of 3 feet: A .-�- Wifer tahle depth SEPTIC TANK El Type/Mfg Li r Capacity 4lc No. Compartments PKG. TREATMENJ PLT. © y Yom— Method of Dispos �1--iDistance to nearest:. Well Foundation J/4 Property Line Y � LEACHING LINE No. & Length of lines </�-/UO 1` Total length/size FILTER BED ' ,❑ Distance to nearest: Well-/� Foundation Property Line aST7 SEEPAGE PITS l I Depth SizeNumber SUMPS Ll Distance to nearest:, - Well Foundation Property Line DISPOSAL PONOS L - I hereby certify that t 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 Di$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 compefll;ation 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." ` c t The applicaift must call for are )red in ctions. Complete drawing on reverse side. w Signed X' ��!/<` I/mss '� Title: �e.r �J Date: d A5 FOR DEPARTMENT USE ONLY Application Accepted by Date �S Area 21 10 Pit or Grout.Inspection by Date Final Inspection by Dat er-r _! Additional Comments: ❑ Stk 466-6761 ❑ 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/+!p/ INFO AMOUNT DUE AMOUNT fREMITTED CK CASH RECEIVED BY DATE �P}ERMITT''NO. + EH 13-241R .�i// i �(/ Li1 C)-22--91 f EH 14-26 }