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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/of 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. �' g r / t Jab Address f�J City 1A Lot Size O X [7 Ur PM r Owner's Name ;, SSS �', )rs. ! (Address r te ,"G g2 r Phone Contractor.c2wla FV— Address �!� 190 License No. PW e - 3 TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i 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 ❑ G�Iavel Pack ❑ Tracy Type of Casing Specifications 1"1 Public Ll Other Cl'DeltaDepth of G�out`Seal`— ' � ^ Type-of Grout I I Irrigation ---;Approx. Depth 1,1 Eastern Surface Seal Installed by I 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 INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIONA iNo septic system permitted if public sewer is 11, vailable within 200 feet.) I Installation will serve: Residence� `Commercial Other Number of living units: '� Number of bedrooms s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK —Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I! LEACHING LINE ❑ No. & Length of lines Total length/size 0 I FILTER BED ❑ Distance to nearest: Well Foundation Property Line it SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: well 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 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature t 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 re e y Tspections. Complete drawing on reverse side. v� y� Signed 7 Title: ( 7hLQ 14 Date: FO=PARTMENX T USE ONLY Application Accepted by Date 15Area Pit or Grout inspe tionby Date Final Inspection by / l/ / Datej � Additional Commen II' Cl Stk 466-6781 ❑ Lodi Ii 369-3621 ElM n ca 823-7104 E) Tracy 835-6385 Applicant - Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I� INFO FEE AMDUNT DUE AMOUNT REMITTED H RECEIVED BY PATE PERMIT ND. a.EH 1 }Z4 IAEV.I/R 5) 4 EH 14-28 �i. �� 7