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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HALELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete in Triplicate) 32 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. (J p�,, / / 3 F-r il��ill\ 1 r�1� C�-�— 100X 3 as 1 4 Jab Address (�'., / 1 City Lot Size!�► _ PM Owner's Name 1J i L L " '^T j.� �e Address �.L+ 1A WIto 2: —p if Contractor's Name S -n•, License No. 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 El 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 ❑ 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 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION EDDESTRUCTION El (No septic system permitted if public sewer is X available within 200 feet.) Installation will serve; Residence/ Commercial Other Number of living units: Number of bedrooms F ' Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK Type/Mfg LL '6 Capacity 1 ?-LLti No. Compartments V— PKG. TREATMENT PLT. ❑ C^� �J Method of Disposal Distance to nearest: Well Foundation 1 Property Line S �-70t LEACHING LINE ;2F—No. & Length of lines k �� f1 __ Tota L length/size FILTER BED ❑ Distance to nearest: Well Foundation 42 :Z Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: W011 Foundation 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all quire d 'nspections. Complete drawing on reverse side. r�f Signed Title: Date: ^ Al^ C 0 `` FOR DEPARTMENT USE ONLY p // Application Accepted by Date 17—OV-01 Area Pit or Grout Inspection by 4 ate a- `{ Final Inspection by _ Date r�^ / Additional Comments: ]� ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy, Applicant- Return all copies to: Environmentalea h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NO. + EH 3-24(REV.141831 (� L, J f - EH 1426 J 1111