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APPLICATION FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 4 (Complete in Triplicate) Application is heiebK 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 Q!2 44 City 570C-HhiJ-L Lot Size . JS PM Owner's Name Address � :2 /szi" T Phone / Contractor t Address License No.�2C'1r;;-6 I Phone4r.- _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0?, DESTRUCTION W: PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1�oT SEWER LINES DISPOSAL FLD. PROP. LINE L1007 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation 12`l Dia. of Well Casing ® Domestic/Private W Gravel Pack ❑ Tracy Type of Casing TeH 1669 Specifications r f"1 Public ❑ Other 17 Delta Depth of Grout Seal _JT�q" Type of Grout�u7o�1r_E I I Irrigation 12e.Approx. Depth I i Eastern Surface Seal Installed by ,1-1n, f r J Repair Work Done ❑ Type of Pump PQ-13 H.P. State Work Done_. Well Destruction Well Diameter �_.� Sealing Material (top 501 �3 ESL YLs Depth 12A3 ' Filler Material (Below 501 � TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) 4 Installation will serve: Residence— Commercial_ Other V�1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg H Capacity No. Compartments :00.1TREATMENT PLT. El _- Method of Disposal Distance to nearest: Wel! ' -- Foundation Property Line . . LEACHING LINE ❑ No. & Length of lines Total length/size FILTER 13ED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ 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 Dl1trict. 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 must call for all required inspections. Complete drawing on reverse side. Signed Title: /r:2% Date: FOR DEPARTMENT USE ONLY Application Accepted by Date t/ 6 V Area (19 . V, Pit or Grout Inspection by ✓'l�Dat® �Fina1 Inspection by 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO, r EH13-241REV.1/851 EH 14-28