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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address /)�c�._ / City / Lot Size 4 PM Owner's Name Address IWA�A)e Phon Contractor .Address L4�? . y�� License No. Phone i�2 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 ❑ Open Bottom -❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation- -----Approx. Depth � CI-Eastern -Surface-Seal-Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Faller Material (Below 501 O TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �� available within 200 feet.) Installation will serve: Residence_ Commercial 'Other ,3.,r l) ®csrsKl Number of,living units: -4--- Number of bedrooms . Character of soil to a depth of 3 feet: �? - _ Water table depth A> SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartmente.: 3i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WeIj, ) Foundation Property Line 1 ry i JE LEACHING LINE ❑ "'No.,& Length of lines m ^Total length/size FILTER BED ❑N Distance to,nearest: Well,,; ��Foundafign, .� l F' ��_ Property Line 6 F SEEPAGE PITS ❑ Depth- ` `�: Size Number r SUMPS ❑f ,Distance to nearesty wellt. Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this appl'rca-tion anal 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 agents9 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 irhsuch 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 cbmpensa- tion laws of California." F iThe applicant must call for all equire spections. Complete drawing on rdverse side. Signed Signed ' Title: e?�'u Date: '16 � _ d FOR DEPARTMENT USE ONLY- Application Accepted by.r • W ` ' r Date ` �r Area Pit or Grout Inspection by Date Final Inspectionby � 4 Date "Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental a th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE . i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. + 14REV.i/e 5) / 'EHfH 3-24 14-28 .- - •C:a Gam' e- - -- - -- r�/3 '_'�