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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. 2ip d.2 ��iA7�-� City r Lot Size l`� c PM Job Address Owner's Name a..17. /M�(:!0 !E1 Address a2Q � 6/e4W_71-1� �� /phone Contractor's Name License No. Phone TYPE OF WELLIPUMP: 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 ❑ 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 ___�4pprox. Depth ❑ Eastern Surface Seal Installed by s _44 Repair Work Done ❑ Type of Pump H.P. State Work Done Q Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 tV a TYPE OF SEPTIC WORK: NEW INSTALLATION7k REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ;" Installation-will serve:,,Resideihce 4 Commercial"— Other } Number of living units:-)— Number of bedrooms 14 11 Character of soil to a depth of 3 feet: 4 De 25 tip • ' Water table depth 52) SEPTIC TANK � Type/Mfg j/- - '��, Capacity L-No. Compartments,, , PKG. TREATMENT PLT. ❑ �+G� r Method of Disposal Distance to nearest: Well Foundation Property Line_e�? �7 , LEACHING LINE No.A.Lengthoflines 11*1-4(61 Ir-T f_ Total.length/size �T FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth FT Size 7 ke)117 Number SUMPS j�{ Distance to nearest: Well Foundation Property Line` DISPOSAL PONDS !❑ 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 a ' employ any person in such manner as to become subject to workman's compensation laws of California." Contractoes hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued;1 shall employ persons subiect fo workman's compensa- tion laws of California." _ The applicant must call for all requir d inspections. Complete`drawing on reverse side. ' Signed X � �� - Title -Date: _ --FOR DEPARTMENT USE ONLY 3, Application Accepted by 'r- Date/`'/ �y Area D Pit or Grout Inspection by Date Final Inspection by.' Date k 4 Additional Comments: "" - :❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 ` ,Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.�XA 95201FEE K; INFO AMOEJNT,DIfE_, _ _ ,AMOUNT,REMITTED_... CASH" I�RECEIVED.BY. DATE PERMIT'NO, EH 13.24(REV.10183) j V �.:: EH 14-26 -