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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Y I v 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 Rules and Regulations of the San Joaquin Local Health District. Job Address 1 (0993. ...C_l C r City� A 11 Lot Size 440�� PM Owner's Name Sm � Address # Brandi 00 - Phone I– 1 onlractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE REA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout – I I Irrigation —.,Approx. Depth l I Eastern rface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence)(– Commercial— Other Number of living units: –I— Number of bedrooms Character of soil to a depth of 3 feet: t4ayd R--n Water table depth SEPTIC TANK IR"Type/Mfg &-a4e c Capacity I. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well -13004 Foundation.-Q--L Property Line 504 LEACHING LINE L�' No. & Length of lines cc)= X R7.P=k Total length/size FILTER BED 20–�Distance to nearest: Well S 011. Foundation `1 o Property Line ;500 ._._..._ SEEPAGE PITS IW–Depth ,2S P* Size s _ Number x SUMPS ❑ Distance to nearest: Well Foundation '+ Property Line saV } 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, 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, l 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. Q Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byV Date `Z'S�'�Jn� Araa w _ IDplicant r Grout Inspection by Date __?__4_7. Final Inspection by "�' Date tional Comments: S. 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ` h ! + EH 13-24 iREV,1/851 9 0 � "�'�' � 3� [ Qi( _ CtW� "') r 2( ,I