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APPLICATION FOR PERMIT 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 �� K1 Ci Lot Size PM 2Owner's Name 1 S� r '�=d Address b 44-10�v Phone -Contractors.Name 'f W License No. 3ozF Z��. Phone TYPE OF WELL/PUMP: : NM WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � -•----_ --+. FOUNDATION - -AGRICULTURE-WEL=L ---- -OTHER-WELL 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 Specifications ❑ Public M ❑ Other T ❑ Delta _'Depth"of-Grout.Seal Type of Grout l ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. � State Work Done Well Destruction ❑Well Diameter's"� Sealing"Material-ftop 50'1— f 0 r Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public-gewer is available within 200 feet.) Installation will serve:. Residence Commercial_ Other ,. 1� Number of living units:---L----Number. f b drooms Character of soil to a depth of 3 feet: Water table depth lLC1 SEPTIC TANK 21" Type/Mfg L Amn_,# (f� Capacity,//.,o b No. Compartments PKG. TREATMENT PLT. ❑ .Method of Disposal Distance to nearest: Well ae Foundation b .Property Line LEACHING LINE No. & Length of lines '' -6 Total length/siz 1,249 y FILTER BED ❑ Distance to nearest: Well 115Q L&� Foundation 10 Property Line Q I SEEPAGE PITS fid Depth. Size "� Number -� SUMPS ❑ Distance to nearest: Well 1. 112034 FoundationPitProperty Line DISPOSAL PONDS Clt 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 P 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."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 must call for all required inspections. Complete drawing on reverse side. " Signed Title: . Data:FOR DEPARTM NT USE ONLY _ Application Accepted by Date Are r� itit�r Grout Inspection by ate Final Inspection by �rs'L Date Z�f V Additional Comments: l ❑ 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. Bax 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24 EH 1426(REV.101831 S• C,0 I V b/,sn i