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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 O/1/ G Lot Size PM Owner's Name A\ dress I.49. 75% . -5Q 1 .A/ ` /l Phone ContractorY/ -aDrtJ �Addre s d IV, /CSO �A icense No...7.� yc3 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 ❑ 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 501 `n Depth Filler Material (Below 501 N TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ' DESTRUCTION ❑ (No septic system permitted if public sewer is -available within 00 feet.) � - Installation will serve: Residence_ Commercial_ Other—o"', TRN i Ar1,�0A Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SagAiL&A e?_ Water table depth SEPTIC TANK Cl"Type/Mfg Capacity .1e260 fdo. Compartments . — PKG. TREATMENT PLT. ❑ Method off�� , fD�isposal Distance to nearest: Well lw� Foundation_2S!f ( Property Line,�� LEACHING LINE W?""No. & Length of lines 3- 90 1 Total length/size y FILTER BED 0—Distance to nearest: Well Z6/7"' Foundatio' AS4-201— Property Line O/416' SEEPAGE PITS ❑ Depth Size t Number SUMPS ❑ Distance to nearest: Well 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 certifythat 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 Califoraia."-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 ust ca or all re uired inspections. Complete drawing on r verse side. 1 -13-97 p Signed X �' Title: A , Date: ! X 13'-o 7 ri �— FOR DEPARTMENT USE ONLY jj Application Accepted Date l" Area /_3 Pit or Grout Inspection by Date Final Inspection by�J Date 2,0�7 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. INFO CASH + EH 13-24(REV.)/85) EH 14.26 �r v i