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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 456-6781 . PERMIT EXPIRES i 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. 7 AC Job Address L g DwACity Lot Size g �~ PM t `Owner's NameAddress Phone Contractor ., _&iTA_ Addfess License Phan,_ �+ TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ tt 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 Wel Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I E Irrigation _.-Approx. Depth I] Eastern Surface Seal Installed by - Repair Work Done .❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) -installation will serve: Residence jk_�CommerciaiOther Number of living units: _� Number of bedrooms_ Character of soil to a depth of 3 feet: fln F � .' .1 Water table depth SEPTIC TANK ❑ Type/Mfg p_ -_�. . - - Capacity__ No. Compartments 14 1 ^ PKG. TREATMENT PLT. E3 '—!Method sr- . 'Method of Disposal Distance to nearest: Well _,mac _ Foundation 1_/o Properiy Line LEACHING LINE ❑ No. & Length of lines 1&tb 77� Total length/size O' F� FILTER BED F] Distance to nearest: Well�r'tFoundation roperty Line 15992 of4f'r4 SEEPAGE PITS 11 Depth Size --,Number SUMPS 0 Distance to nearest: 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 District. i Home owner or licensed agent's signature certifies the following: "I certifythat 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 confpensation laws,of California." Contractor's hiring or sub-contracting signatute 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 must call for all required inspections. Complete drawing on reverse side.' Signed X -� Title: 017 e 1� Date: x Lo. DEPARTMENT USE ONLY Application Accepted by41� Date S Area Pit or Grout Inspection by Date Final Inspection by &&e Date Additional Comments: ❑ Silk 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 r^ FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH ♦ EH 13-24/REV.i/n sl —70 EH 14-26 / i