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1 a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 F / 46Zk k9 City Lot Size PM Owner's_NameJ�_ --� Address � ?� Phone 7,0 Contractor / !` Address., License No. O.S~ .� Phone_ � c. TYPE OF WELL/PUMP:. .; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D 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 F) Public F1 Other F.7 Delta Depth of Grout Seal Type of Grout _ I I Irrigation ..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 501 Depth Filler Material (Below ') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION IV DESTRUCTION ( I (No septic system permitted if public sewer is / available within 200 feet-) Installation will serve: fiessi�dence Commercial_. Other-l" Number of living units: r Number'of b_edr ms l � ` Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK f>4/Type/Mfg Capacity/— 4 No. Compartments 2-- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well —c; Foundation Property Line....f. U_..�-_ LEACHING LINE Rl"No. & Length of lines ca Total length/size 1 FILTER BED 17 Distance to nearest: Wp ell 9T Foundation Property Property Line 15O 11 SEEPAGE PITS 'Depth r2 S Size Number 2 T SUMPS _. Cl Distance to nearest: Well� Foundation l .r_- Property Line 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, 1 shall employ persons subject to workman's compensa- tion laws of California." V11 The applica �rtust call f r all equired inspections. Complete drawing on reverse side. Al Signed X '.� Title: 0(d)Ak-f Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pi or Grout Inspection by Date 17 Final Inspection b Date 6 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box,2009,.,Stk., CA.95201 FEE INFO AMOUNT DUE +A+M�O�yUNTJREMIaTTED CASH RECEIVED BY DATE G� PEERRMIT'NO.�� +.EH 13-24(REV.tinb) 2e. d / V Ll �V' �� E_J ~Cj • tJ EH 14-26 �O