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i APPLICATION FOR PERMIT �— 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) 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address _ ��lsd© ,vys,*w Aeie City d!%W* to Lot Size PM Owner's Name ,/1 �' �� 5- Address s'/4-47 r° Phone Contractor L OM 92O/y Address License No. Phone TYPE'OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \ DISTANCE TO NEAREST: SEOTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL 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 "`� ""' '�` 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. State Work Done Well Destruction ❑ Well Diameter Sealing Material.(top 50') Depth Filler Material (Below 50') TYPE OF SEPTI 'WORK: NEWINSTALLATION& REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L Commercial Other Number of living units: / Number of bedrooms 3_" ` Character of soil twa-depth of 3 feet: OrAfAlolf �- ` Water table depth SEPTIC TANK Type/Mfg #4*30c' C.4lT Capacity /.400 No. Compartments 2 PKG. TREATMENT'PLT. ❑ -...._Me-. � thod of Disposal - Distance to nearest: Well -4-0 Foundation Property Line 2 LEACHING LINE I? No. & Length of lines .X" '>0.4Total length/size l O 4F FILTER BED ❑ Distance to nearest: Well Foundation 90 ' Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property ine DISPOSAL PONDS ❑ 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, am\ 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 ti 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 II for all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY l Application Accepted by /��tel/ Date �� w fp Area Pit or Grout Inspection by Date Final Inspection by` / t Date Additional Comments: ❑ �tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 -,Applicant- Return all copies to:-Environmental Health PermittServices 1601 E. Hazekon Ave:; P.O. Box 2009, Stk. CA 95201-- - FEE o1 AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT"N0. EH 13-241REV.t/s5t -7V .Qty c� -� O EH 1426 �f o