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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. Job Address 3&F GTYO AJ 4 LIC— City -7 Z_A�'J Lot Size Pm Owner's Name Address Phone e Contractor Address License No. Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1-1 PUMP INSTALLATION .❑?• ' SYSTEM REPAIR ❑ t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE •�d� FOUNDATION a AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other 71 Delta Depth of Grout Seal Type of Grout I 1 Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done V" Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [ I DESTRUCTION { I (No septic system permitted if public sewer is da f s available within 200 feet.) �. Installation will serve: Residence Commercial_ Other ; Number of living units: _.._._I_, Number of bedrooms Character of soil to a depth of 3 feet: C LAY - Water table depth SEPTIC TANK Cdr Type/Mfg Capacity)2b0 No. Compartments Z l PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well DO Foundation /O Property Line 30 LEACHING LINE L�No. & Length of lines z g,.T/ Total length/size 170 'X Z Ir FILTER BED ❑ Distance to nearest: Well Z00 Foundation 7-0` Property Line SEEPAGE PITS M Depth yS r ---Size- 3 .� Number 2— SUMPS Ll Distance to nearest: Well 1749 Foundation /3a 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 i 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 if 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 side. S _ Signed X z -1%t.--�a� Title: L1»r/1�t� FOR PARTMENT USE ONLY / Application Accepted by Date a it Area r Pit or Grout inspection by Data Final Inspection`by Date g� C Additional Comments: �-L`^f 4.E Z�► f . yJ b :2 ca iJ rJ' __ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantace823-7104 ❑ fracy '835-6115 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMI7'NO. INFO EEM H t4-241REV.rinb) `—`7o-. � 115 Y`