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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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size .G 0, 14 PM Owner's Name s� a rYl o Phone S t? Contractors / Address License Na. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL TION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL FLD. —PROP. LINE 3VQ FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS r — 4TENDED 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 ('l Public Specifications Other ❑ 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 O Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I I septic system permitted if public sewer is UJ Installation will serve: Residence_ Commercial_ available within 200 feet.)Other Number of living units:r Number of bedrooms OQ Character of soil to a dof 3 feet: S4? zt t/ Water table depth epjfl SEPTIC TANK r Type/Mfg Capacity---:-P Y No. Compartments !� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well WO Foundation IQ r Property Line v' LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well 1"0 Foundation ep r Property Line 640 G SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state jaws, 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 call for all r .Complete drawing on rev ide. Signed Title:_ X_�tj _ Q Date: !! X10 FOR DEPARTMENT USE ONLY Application Accepted by �f�C_J� Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 Qy FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT'NO. r.EH 13-24(REV.i i e 5) - / EH U-28 `V 25`� t LIZ I/ —379