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I APPLICATION FOR PERMIT SCAN JOAQUIN LOCAL HEALTH DISTRICT 1601E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete.in Triplicate) Application is hereby made to the San Joaquin ocal 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. 4 Job Address ` A/' ' -IIII�� City J-4 -P'" Lot Size PM jam, c, �-' ��eC Owner's Name v 3w, ✓ hf Address 0,4).K L�� '��t h Phone Contractor . �—> AlLress License No. Phone_ TYPE OF WELL/PUMP: NEW WEfLL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANGkZXQ NEAREST: SEPTIC TANK I' SEWER.LINES DISPOSAL PROP. LINE FOUNDATION �I• AGRICULTURE WELL HER WELL PITS/SUMPS _ INTENDED USE TYPE 0 711 PROBLEM ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom f an '--�Dia.�-of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave 0,Tracy Type oo 'C i q Specifications M Public ther �' ❑ Delta Depth of Grout Seal Type of Grout I I-Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work.Done ❑ Type of Pump f H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth �f Filler Material (Below 50') NV TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I.I DESTRUCTIO (No septic system permitted if public sewer is 1G available within 200 feet.) ' Installation will serve: Residence_ Commercial_. Other Number of living units: Number of bedrooms [ 4 Character of soil to a depth of 3 feet: �p - Water table depth IIII SEPTIC TANK ❑ Type/Mfg iIP Capacity No. Compartments PKG. TREATMENT PLT. ❑ 0 Method of Disposal " Distance to nearelI�t: ` Well Foundation Property Line i! LEACHING LINE ❑ No. & Length of lines Total length/size, FILTER BED ❑ Distance to nearest:' Well Foundation Property Line j r SEEPAGE PITS I I Depth �P Size Number III 'Ii ' s SUMPS ❑ Distance to nearest: Well Foundation Property Line fy DISPOSAL PONDS ❑ k 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 I.:Mealth Di§trict. 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 1 r 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." lh The applicant st 11 for all require inspectioNNhns. Complete drawing on:reverse side. Signed X �' I, Title: Date: FOR DEPARTMENT USE ONLY _ Application Accepted byIt' Date Area I Pit or Grout Ins II pecti Date Final Inspection by Date E Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 - 1'❑ 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 95201FEE $$$ ti INFO AMOUNT DUE A113-S. MOUNT REMITTED CK RECEIVED BY G DATErPERMIT'NO.I. r +.EH13-24(REV.iiNs)EH 14-26