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I 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District..,, . I Job Address f3 AW ST reap City Lot Size PM 1'd%anZI Address Z t" l Phone Owner's Name ` A Contractor's Name �� oLicense'.4o.' Phone N TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ \ PUMP INSTALLATION ❑ i SYSTEM REPAIR ❑ OTHER 11 ' DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK I -,,.SEWER LINES O FOUNDATION I l r' r AGRICULTURE WELL OTHER WELL PITSISUMPS A INTENDED USE TYPE OF WELL !PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing � , r n.Bottom -i ❑ Manteca Dia. of Well Excavation ❑ Industrial ' Specifications Q'0�^ ,. i � !.Type of Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy rType of Grout ❑ Delta Depth of Grout Seal EJ Public ❑ 0iher [I Irrigation �pprox, Depth ❑ Eastern��',t 1,Surface Seal Installed by .H P State Work Done' Repair Work Done ❑ Type of Purrlp3' ;'- ! {,rte fi Well Destruction El Well Diameter } k Sealing Material (top 50'} 3. Depth } (Filler Material (Below 50'} 'I. TYPE OF SEPTIC WORK: NEW INSTALLATION{{ LI.. REPA}IR/ADDITION DESTRUCTION ❑ availablle'with within feet.) Installation if public sewer is \ Installation will serve: Residence Comm iercial XC" Other ` Number of living units: ' Number of bedrooms ja Water table depth JtQ Character of soil to a depth of 3 feet: SA • s'rr;. Capacity__,.__ No. Compartments I j � � � SEPTIC ❑ ITypelMfgtirtx, � . r Method of Disposal PKG. TREATMENT'PLT. ❑ 0Property Line Distance to nearest: Well Foundation LEACHING LINE Q No. & Length of lines Total length/size k--, -.',Z A�_1. !.oGO' Foundation — Property Line k FILTER BED ❑ Distance to nearest:' i f Number SEEPAGE PITS ❑ Depth Size 1 SUMPS ® Distance to nearest -Well -� Foundation Property Line ; DISPOSAL PONDS ❑ f 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 I for all required inspections. Complete drawing on reverse side. G- 7_ 8, I I Title: i Date: Signed a FOR DEPARTMENT USE ONLY L 4 Date -7 �� rea Application Accepted by Pit or Grout Inspection by f 1 Date Final Inspection by Date Additional Comments: X ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $35-6385 Applicant- Return all copies'to: Environmental Heakh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s � FEE --EK T' RECEIVED BY DATE PERMIT'N0. INFO AMOUNT DUE AMOUNT REMITTED CASH l- + EH 13.24[REV.10/831 EH 14-26 "�'�