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APPLICATION FOR PERMIT ' J SAN JOAQUIN LOCAL HEALTH DISTRICT # 1601 E. HAZEL 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. j�� Job Address 6D � �� City ' '—' +` Lot Size �• 5&c�ypM Owner's Name /Yr ogAU— D. S—cx Address Phone I Contractor eJW 4516— Address License No. " Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__ PROP. LINE "1 FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS e° INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Pia. 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 Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 509 Depth Filler Material (Below 501 f^ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is A00' � available within 200 feet.) Installation will serve: Residence Commercial-- Other Number of living units: -_.L- Number of b oms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity &00 o. Compartments .Z PKG. TREATMENT PLT. ❑ Method of Di offal Distance to nearest: Well Id Foundation Property Line LEACHING LINE CR�'No. & Length of lines /�-� Total length/sized FILTER BED 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ir-Septh 2— Size36 le Number SUMPS �E] Distance to nearest: Well/�D Foundation Property Line DISPOSAL PONDS ❑ 1 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 ormance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant,2pst cal or lir i cti o lete drawing on reverse side. Signed X Title: /1�/.L>�( f�.�^'— Date: FOR DEPARTMENT USE ONLY / Application Accepted by Date Area Area `7 6 Pit or Grout Inspection by 1 Date l� Fiinafl Inspection by Date �o Additional Comments: � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 638.5 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY `DATE PERMIT'NO. + EH 13-24(REV.t/B 5) O -^_moot EZ~,50 EH 14-26