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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. Job Address 2-7 7. 02PELOtAoY �/�� - city , qq Lot Siz PM Owner's Name Address dy f @�LlnTat (A) �� 3s 7 Contracto �[ Address [e� I�� ( License No. - Ph,.,3-6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-L-3 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 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C1 Domestic/Private ❑ Gravel Pack ❑ Trac T Dia. of Well Casing --A V Type of Casing Specifications ❑ Public ElOther ❑ Delta Depth of Grout Seal ❑ Irrigation —A Type of Grout pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - State Work Done Well Destruction 111 Well Diameter Sealing Material {top 50') Depth Filler.Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence v Commercial_ Other available within 200 feet.) Number of living units:–1_ Number of bed r ms 3 Character of soil to a depth of 3 feet: SEPTIC TANK Z-'Type/Mfg Water table depth s PKG. TREATMENT PLT. ❑ Capacity A9–( _Q No. Compartments y r Method of Disposal Distance to nearest: Well7� Foundation 20 Property Line 6� — LEACHING LINE No. & Length of lines Total length/size- N ZZ FILTER BED ❑ Distance to nearest: Well x" - r 1� Foundations property line r SEEPAGE PITS 93"Depth T Size ' Number_.�„ I ! SUMPS ❑ Distance to nearest: Well s ' .-.Foundation��_ Property Line •— DISPOSAL PONDS ❑ r 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: "1 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 at call for all uir inspections. Complete drawing on neve - 'de. Signed Title: Date: za FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Iz Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK 9 INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241nEV.t/e51 ' EH 10.28 6 *�0C