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' I APPLICATION FOR PERMIT ( � SAN JOAQUIN LOCAL HEALTH DISTRICT 1� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. City Gt742 E Lot Size �u PM Job Address Ci .T-. y Owner's Name Address l 702 /4 Phone 2.2 Contractor/ Address /- r p� �` �� License No.J0570 Phone 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 ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ---Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 r TYPE QF SEPTIC WORK: NEW INSTALLATION i REPAIR/ADDITION l 1 DESTRUCTION I I iNo septic system permitted if public sewer is .4p available within 200 feet.) Installation will serve: Resid/ nee— Commercial_ Other Number of living units: r Number/ofbedrooms 2 L !cV - Co/�4w Water table depth0 r f� Character of soil to a depth of 3 feet: SEPTIC TANK 191 Type/Mfg e-or3 ( A6 ?40 ___ Capacity Z692& No. Compartments �- PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation /0 Property Line„3oy LEACHING LINE ff2r' No. & Length of lines 2 Total length/size � FILTER BED Distance to nearest: Well r.?s � l , Foundation s 1 Property Line SEEPAGE PITS 14- Depth S Size Number SUMPS Ll Distance to nearest: Welt 0 Foundation ��f Property Line 3 JV f 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call r al required inspections. Complete drawing on reverse side. Signed X Title: Date: it: RTMENT USE ONLY C, Application Accepted by r Date y Area Pit or Grout Inspection by Date Final Inspection by Date 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CAS INFT I RECEIVED 13Y DATE F ERM11'NO. + EH 13-241REV,1/851 EH 14-26