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APPLICATION FOR PERMIT j 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) I Application is he+eby 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 _.T��/ d, �/�' /� City Lot Size PM Owner's Name _-_.__..__.._ UL`s Address El,;�-/,2'"A11) Phone Contractor_ 04 v 4,o Address 1 �i='�Address O Q � 9 , ed�&_ � �License No. � Phone_ TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.-of Well Casing t ❑ Domestic/Private- ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ___Approx,_Depth l I Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump `s ti. H.P. State Work Done _ Well Destruction ❑ Well Diameter +.1 Sealing Material (top 501 Depth Filler Material (Below 501 _ N TYPE_OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is .*" {J "'"" r''0 1'A available within 200 feet.I y1 Installation will serve: Residence_ Commercial Other # Number of living units: ---I. _ Number of bedrooms Character of soil to a depth of 3 feet: Ap $ Water table depth SEPTIC TANK ❑ Type/Mfg " "" '� Capacity No. Compartments PKG, TREATMENT PLT. ❑ ." Method of Disposal Distance to nearest: Well Foundation Property Line p LEACHING LINE No. & Length of lines ` '. Total length/size FILTER BED Distance to nearest: Well �Foundation- —F2 Property�Line /� I� % — ? I SEEPAGE PITS I 1 Depth j Size Number F" 7' ' d..._ SUMPS L] Distance tp nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a 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 ^-�- «r•�.. - �.- - 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,l,shall employ persons subject to workman's compensa- tion laws of California." 1 The applicant must call for II req "red inspections. Complete drawing on reverse side. i [ t l Signed X Title: .n-�''-�� k __ Date: ��/47 FOR DER AFtTME S 'ONLY Application Accepted by Date JlVfid`XK Am. i r6 - Pit or Grout Inspection by Date Final Inspection by to c ! Additional Comments: A t ❑ Stk 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,96201 yd.-,..ter...-.. .....�...w+. -. +w -_. ..... wr aw r.w.. w i.r....rr.eo-r ,. w.wwux a.�Yr -Iwye• sr�•T. - .A,...r ..eaw�. O�w......-.+rw��.�nr.+.....,_��r+�s�R...y.a FEE 1^ r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT,,NO. r.EH 13-24(REV.I/K5) EH 14-28