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APPLICATION FOR PERMIT I -SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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, Job Address Cite Lot Size -5�00X/.5,dpM Owner's Namt � L Address - Yin F— ~ Phone Contractor's Name' _ it ense No. �y�-T u '- —" phone - 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 �-A f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN7E_NDED_U_SE ___TYPE OF WELL. PROBLEMA_REA__CONSTRUCTION SPECIFICATIONS ❑ Industria( ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Done" tel. Well Destruction ❑.s_Well Diameter SealingMaterial-{top 50'1`' A =' I 0 -,'Depth Filler Materiai'{Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION m-.B£STRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:: Residence—i commercial_ Other # Number of living units: Number"of-bedrooms--- - j Character of soil to a�depth of 3 feet: Water table depth SEPTIC TANK F 11Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` Method of piT5SI Distance to nearest: Well Foundationf iProperty Line I . j LEACHING LINE D---W. � Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS- ; Nl/Gepth _ 6=,5 -Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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. . 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, 1 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 compense- t n f California." �. s Thea plican ust call o all requir inspections. Complete drawing an'reverse side. 3 ` (. t Signed r Title: ' !� o r , Date: FOR-DEPARTMENT USE ONLY Application Accepted by w `� I/ Data Area Pit or Grout Inspection by��Date Final Inspection by � Date Additional Comments: QAk 466-6781 LILodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 cant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE I PERMIT"N0. i EH1324(REV.10/83) EH'14-26