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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-8781 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. Job Address + �+ / �f l n� (5N. Avg. City ESCt-10 0 Lot Size + a �s PM ''Owner's Name LJ� "' ,flr r .__. Address-E 775 .--6�fLOeI,.�Q. _ ESC-4 101`� Phone 9� 23g m ` Contractor's Name G-0 4AoS License No. Phone J`' a �gQ7� tC It � a(` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION LlSYSTEM REPAIR ❑ OTHER LJ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � .M DISPOSAL FLD. """ PROP. LINE FOUNDATION —,AGRICULTURE WELLi 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 ❑ Gravel Pack ❑ Tracy ,Type of Casing ,rd Specifications .❑FPublic E,Other_. . . El Delta Depth of Grout Seal _ Type of Grout ❑ Irrigation'"" """-1: Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ir REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence V/ Commercial_ Other �. Number of living units: 1 Number of drooms Character of soil to a depth of 3 feet: Aadbec Water table depth ` SEPTIC TANK 0J Type/Mfg �Ncipr_�� Capacity I oo No. Compartments PKG. TREATMENT PLT. ❑ H rMethod of Disposal e Foundation Pr Distance to nearest: Well 15� � Property Line 7S " 1 { LEACHING LINE No. & Length of lines Total length/size ! FILTER BED ❑ Distance to nearest: Well - Foundation Property Line SEEPAGE PITS ❑ Depth Size Number sv S 'SUMPS - - �- Distance to nearest: Well>_�200, -Foundation- --Property Line DISPOSAL PONDS ❑ 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. 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."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." The applicant must call forrequired inspections. Complete drawing on reverse side. f Signed { 4� e.. u.�,�. Title: Date: FOR DEPARTMENT USE ONLY f Application Accepted by C- l n _ Date Area alb Pit or Grout Inspection by A� Date Final Inspection by Date— Additional ate—Additional Comments: Yv` ❑ Stk 466-6781 Q Lodi 369-3621 Manteca 623-7104 ❑ 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 RECEIVED By DATE 1'ERMIT'NO. + EH 13-24]REV.10163 EH 1428 1