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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-8781 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 tate San Joaquin Local Health District. Job Address . I b ��E/S => City_C" 9_ Lot Size PM Owner's Name /T V/1! Address ��1 / Phone , Z''b6 . Contractor ddress G Al- License No.Z5j X13 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 12 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material atop 50') Q Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIOqV REPAIR/ADDITIO DESTRUCTION (No septic system permitted if public sewer is oQ available within 200 feet.) Installation will serve: Residence_X_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ` r SEPTIC TANK Zype/Mfg ge le I NJ cz&t& Capacity No. Compartments PKG. TREATMENT PLT. Method of Disposal �_ Distance to nearest: Well-?2 -J-- Foundation D / Property Line /,cv C3 LEACHING LINE � No. & Length of lines -- Total Ven 9th/size 5 0 FILTER BED Distance to nearest: Well ,Ly d"'OL Foundation 5-6 r.._ Property Line_ GVZ2�+ SEEPAGE PITS Depth !O Size 'clX ` Number SUMPS Distance to nearest: Well A_�C'r Foundation /'dCS/ Property Line !�57470 DISPOSAL PONDS ❑ I hereby certify that 1 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 for all required inspections. Complete drawing on reverse siid Signed de. / t�z--rTitle: ��,ast�� Date: �Y L X, ,_., PARTMENT USE ONLY / Q i Application Accepted by Date r 3 Area Pit or Grout Inspection by Date Final Inspection by Date V f a. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE LER NO. INFO CASH p d + EH 13-24 REV 476,6 30 EH 14 26