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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Lk f r_ Job Address City Lot Size Z Owner's Name It Address Phone 12 1 �] v Contractor� ddress ! 00 a �. 16a License No. ©�2�� 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 I7 Other ❑ Delta Depth of Grout Seal Type of Grout �. J 1 I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material atop 50'1 Depth Filler Material Melow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence ✓ Commercial Other Number of living units: _.-_I_._.-. Number of bed! oms . �Q � Character of soil to a depth of 3 feet: �` Water table depth Capacity-&-c! _0 SEPTIC TANK Ell' Type/Mfg Capacity c! No. Compartments PKG. TREATMENT PLT- ❑� f�I r Method�of Disposal Distance to nearest: Well Foundation �/D° Property Line F b length/sizet LEACHING LINE LW &No. Length of lines ��,,rr��Total - FILTER BED BK Distance to nearest: well r Foundation,��tt_ Property Line 767 SEEPAGE PITS A<—Depth Size `. _N umber SUMPS ❑ Distance to nearest: Well t Foundation ��.`7_ Property Line 7 DISPOSAL PONDS ❑ ' t. I hereby certify that I have prepared this application and that the work will b_a done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I 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 whiff h this perinitis.issued,I shall employ persons subject to workman's compensa- tion laws of California." " The applicant I�Ustall for all regeired inspections. Complete drawing on reverse side, ' 3 Signed X Title W Date: FOR DEPARTMENT USE ONLY Date vv ' Area Application Accepted by _ Jit or ��Grout Inspection by fivy/J7 ate J` Final Inspection by Date 4-471— 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,.Sik., CA 95201 p� FEE AMOUNT DUE AMOUNT REMITTED CAAKSH f RECEIVED BY DATE PERMIT'NO. INFO f —,2n7 7��r lr�tvlJ //L -A,� + EH 13-2�IpEV.t i x 51 EH 14-2a