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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 IComplete 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 L4 —7 n`� ' V City N Apr-reCtJot Size 26 4C4-3- PM Owner's Name 44 Address Phone �= — Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 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 ED Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t-I Public n Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation _.Approx, Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION IF'DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet 1 Installation will serve: Residence k Commercial OtY�r r Number of living units: I Number of bedrooms / Character of soil to a depth of 3 feet: <' p Water table depth f SEPTIC TANK lllie�Type/Mfg 4F_471- Gr Cr"Iel _Capacity J_2i(._Q No. Compartments PKG. TREATMENT PLT. Eli t+ / Method of Diisp9sal Aeslat, , Distance to nearest: Well ��" 3 y Foundation [ Property Line LEACHING LINE ❑ No. & Length of lines Tojal length/size FILTER ED *,"Distance to nearest: Well Foundation � ( � Property Line� boo I- S-ge Rn -Z-51 )( w . -ye—rit Si 4 t '2..o X-._71i 140-S;A SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ 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 Di%trict. 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."Contractors 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 mu all for all required in tions. Complete drawing on reverse side. L pp /� Signed X Title- Lo T Date:/_—V r FOR EPAR20ENT USE ONLY Application Accepted by Date rea �/� Pit or Grout Inspection by Date Final Inspection b OateF/' Additional Comments: ID Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO. + EH 13-24 TREY. i n 517© , ,l ��pn p �--y EH 10-28 J`? L