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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT It 1601 E. HAZEL T ON AVE., STOCKTON, CA L Telephone (209) 466-6781 ¢�a PERMIT EXPIRES TYEAR 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. y [( Job Address Aibn City L Lot Size PM Owner's Name en Address Phone e 1/250 Contractor Address License No4718 3 x Phone '64— ice(? 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _. 6- I I Irrigation _--Approx. Depth I I Eastern Surface Seal Installed by _ Repair W rk'Do e ❑ Type of Pump H.P. State Work Done_ t *fir Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION 1.1 DESTRUCTION7y(No septic system permitted if public sewer is .� available within 200 feet.) Installation will serve: Residence X,—, Commercial_ Other Number of living units: Number of b#e#drooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ; 04-Type/Mfg I r---- Capacity UfV1<J7Q!;Lr1 No. Compartments PKG. T�tEATMENT PLT. ❑ p^ (t(5CY L �� Method of Disposal Distance to nearest: Well ._.Foundatjo�l, _ P.roperty_Line-- --- ----�- - ,� LEACHING LINE ❑ No. & Length of lines Total length/size (�'} FILTER BED ❑ Distance to nearest: Well Foundation Property Line •� SEEPAGE PITS I I Depth Size 2_--.___ d Number g SUMPS LlDistance to nearest: Well Foundation Property=Line_.1 ! DISPOSAL PONDS El 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, 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,applica t must call for all required inspections. Complete drawing on reverse side. Signed X _ Title: Date: 10101k7 FOR --A-RTMENT USE ONLY r v Application Accepted by Date Area D Pit or Grout Inspectao _b ---_ i D E-� ' �Final._Inspectio ^~ - Date, Additional Comment9 Yf a e V iV ©CS ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104'`-,, ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental'HealtFi:Permit%Services 1601 E. Hazelton Ave J.O.-Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATEr PERMIT'NO. + EH 13-241REV. /951 ' EH 14