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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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City tjW 4TEf4 Lot Size PM Ir Owner's Name _ / /Q �Z/dIP Address 12 C!/ XF es. 1111—i7e Phone T a a s Phone ' Contractor's Name •�:��L- �..f� License Nb:- - TYPE OF WELL/PUMP: NEW WELL'❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM.REPAIR I❑ 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 Y Dia. of Well Excavation~ Y Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout p ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by C Repair Work Done ❑ Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Materiawtop 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ PESTRUCTION ❑ (No septic system permitted if public sewer is . . __ .` - �, - =.w • , ..S°iQ.0 S`.�^" . s,,« „„ available within.200.fest.) a - Installation will serve: Residence_ Commercial_ Other x`41 Number of living units:. Number of bedrooms /CT- Character of soil to a depth of 3 feet: _ Ali /nd7' Water table depth 16 SEPTIC TANK Type/Mfg Capacity ,1 00' No. Compartments �1 PKG: TREATMENT PLT. ❑ 7- 7 Method of Disposal 4k16"='J !V I. Distance to nearest: Well F Foundation I6Property Line 1A�f C) LEACHING LINE ❑ No. & Length of lines Total length/size :2 F ' FILTiER BED', `V Distance to nearest: Well /16[ Foundation jG Property Line �C3 a SEEPAGE PITS\' El Depth, Size Number e SUMPS ❑ Distance to nearest: ,Well Foundation Property Line DISPOSAL PONDS ❑ Y .� 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 t.a 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 for all requ.ired inspections. Complete drawing on reverse side. t Signed X ��.,�C. / -Title: �- Date: 'XOR DEPARTMENT USE ONLY— Application Accepted by ' ° �l- - Date"3 Area D i. ' � S �. Pit or Grout Inspection by � �� } Date "- Final Inspection by bat i I Iv 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 P ~FEE AMOUNT DUE' ..«. AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. INFO r EH 13-24 IREV.10/831 Li .S, C3 EH 1426 T} u