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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �1 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 4666781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 R41es and Regulations of the San Joaquin Local Health District. Job Adds f r- N `` r, City d O c4 t-1- Size I10� IX O PM M1 f - 1 Q �- Owner's Name 0 �' > ! P� Address 6 � Y AlPhone i 33 Contractor du Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ W LL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.O SYSTE M REPAIR.❑ OTHER 0,� DISTANCE TO NEAREST: SEPTIC TANK SEWER•LINES DISPOSAL FLD. PROP. LINE r—FOUNDATION ; AGRICULTURE WELL _ OTHER WELL'L, PITS/rSUMP,S INTENDED USE TYPE OF WELL.,,,, PROBLEM AREA-.-CONSTRUCTION SPECIFICATIONS- ---_ ❑ Industrial ('L Open Botiom ❑ 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 ".';L'___Approx.bepth ❑ Eastern Surface Seal Installed by I Repair Work Done 71Type of Pumps H.P State Work Done N t ,a Well Destruction O�I"Well Diameter i Sealing Material {top 50'1 ; ) Depth f Filler Material Melow 50'1 Ti " ? TYPE.OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION LL (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence ' Commercial._ Other Number of living units: t Number of bedrooms 2_-J 1 Character of sot!to a depth of 3 feet: 0r a LL _Water table depth SEPTIC TANK 2'�Type/Mfg Capacity 960 No. Compartments Z I PKG. TREATMENT PLT`❑ Method of Disposal Distance to nearest: Well !OO Foundation I O Property Line L Cl LEACHING LINE El N0. & Length of lines a Total length/size FitER-BE'D' ❑ Distance to nearest: Well%Ad Foundation .... Property Lineoe J ; f SEEPAGE PITS IDrDepth " ~._ _Size er SUMPS �f Distance to nearest: Well �P40 r Foundation�`9S Property Line /S #`� 1 t` f 4- DISPOSAL PONDS ❑ "r"" ' '^" "" ""-` I 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 andtregulations 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 f employ a6y person in such manner'as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i 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 m t call for all a uired inspections. Complete drawing on reverse side. Signed ! Title: 0_keqfge,1 Date: FOR DEPARTMENT USE ONLY ' *Application Accepted by I-/1 Date Area Pit or Grout Inspection by ate Final Inspecti n by Date! �p !Additional Comments: Olt 'R5tk 466-6781 ❑ Lodi 369-3621 ❑ Ma6ca 823-7104 ❑ Tracy 5-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 'Box 2009, Stk., CA 95201 FEE _AMOUNT DUE-,. --AMOUNT ftEMiTTED - -RECEIVED BY ^" " 'DATE" �' _-PERMIT'NO. .. - INFO + EH 13-241REV..�/851 - 1� EH 1426