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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. A!VJob Address 146 � City 7A66V V Lot Size PM Owner's Name ki JAY Address �I�[ f c.__ i Phone Contractor 04 �if-, qZ44!Q Address Ira of t _aft License.No. 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 1-1 Public F1 Other F1 Delta Depth of Grout Seat Type of Grout I i Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50') + Depth Filler Material (Below 50') ~' TYPE OF,SFRTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence Commercial_ Other >� Number of living'units: -1— Number of bedrooms - Character of soil to a depth of 3 feet: L=7 A P&A Water table depth SEPTIC TANK ❑ Type/Mfg Capacity "NO. Compartments PKG. TREATMENT PLT. ❑ ��' Method.of Disposal a Distance to nearest: Well ation Property Line LEACHING LINE _ No. R Length of lines` + Total length/size ry� FILTER HED ❑ Distance to nearest: We$04QP_JP7 Foundation . PropetYy Line / I SEEPAGE PITS A I 1 Depth Size _ Numbbr SUMPS ❑ Distance to nearest: Well Foundation + Property Line DISPOSAL POND$` ❑ , 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: "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 fQrdall r red inspections. Complete-drawing on reverse side. g Signed t Title: Date: DEPARTMENT USE ONLY Application Accepted b rJ Date t6 Area —2 4?/X1 Pit or Grout Inspection by Data Final Inspection by Additional Comments: ❑ Stk: 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 ^ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH CK a RECEIVED BY DATE PERMIT*NO. + EH1324 IREV.1 i x 5f J x +�'>,i 1 EH 14-2t1 89