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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/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 O vCity 7"75y __ Lot Size f9Nc i PM Owner's Name 11e 2;X TO$r1q Address Phone Contractor's Name 1�7o iti License No. _/yam �'�� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE N1 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 [7Gravel Pack E3Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State.Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ElDESTRUCTION ❑ INo septic system permitted if public sewer is �! available within 200 feet.) (} o- 17c6;[" IHoM f` V Installation will serve: Residence— Commercial= 0#her j Number of living units: x Number of bedrooms 3 I. Character of soil to a depth of 3 feet: Water tattle depth SEPTIC TANK m Type/Mfg C. s �' Gtis Capacity .2 V017 .'Compartments I.uy PKG. TREATMENT PLT. ❑ ! Method of,Disposal y Distance to nearest: Well—bf E: Foundation A9 Property Line � LEACHING LINE jl2 No. & Length of lines - 3` 90 Total-length/size 2 FILTER BED ❑ Distance to nearest: Well ZeO' Foundation /a Property Line SEEPAGE PITS ❑ Depth Size Number k SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certrfy 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 i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor s hiring or sub contracting signature j 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 muses Il for all required inspections.:Complete drawing on reverse sided " m Signed Title: Date: f 4PR`DEPARTMENT USE ONLY I 7 Application Accepted by Date — — a Area 'x�,r�� Pit or Grout Inspection by Date Final In pection by Date ✓ f Additional Comments: tL3 � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. INFO f. +EH 13.24(REV.101931 EH 14-29 0, Q