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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601,E. HAZEL T ON 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. ( ! ,t Job Address tCZ °d v A), �X.tr ! City Lot Size i? PM Owner's Name Address 00 Phone d ContractoA" Address 1'+� * 'L7 �L7� f License No. 3792 7 (P Phone `Bras 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 pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_v Commercial--Other -- Number of living units: Number of rooms Character of soil to a depth of 3 feet: ' °~� `''Water.table.depth. /6 SEPTIC TANK P3 type/Mfg .tea Capacity/ c� No. Compartments PKG. TREATMENT PLT. ❑ / t Method of Disposal { - - Distance to nearest: Well C t Foundation_ _/O Property Line 1 V-. _. ._-.._.. ._—r LEACHING LINE Z--No. & Length of lines 1 Total length/size Xa r / f r FILTER BED ❑ Distance to nearest: Well + Foundation ICS Property Line s SEEPAGE PITS [Depth �S Size "• ' 3 Number..._ SUMPS ❑ Distance to nearest: Welles Foundation I f) Property Line DISPOSAL PONDS ❑ I he 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`ta`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 roust call for all required inspections. Complete drawing on reverse si e. Signed Title: �. Date: La`,)I� a, FOR DEPARTMENT USE ONLY Application Accepted by ;1�f4 _ _ __ _ __ Date Area 0:! Pi r Grout Inspection by e ? �- Date Final Inspection by Date/ 62 Comments: 4f7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 x FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`'NO. + EH 1426(REV,I/851 � + Q .. ,�p k�45X4 I V -1