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APPLICATION FOR PERMIT IF-2 r 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 �l/ 1 t'J City st-""^N. Lot Size 4q0 X -3 T,6 PM XOwner's Name _# Address l O � `�`�"�- Phone Contractor IR IL Address License No. Phone TYPE OF WELL/PUN NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f _ 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 d L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public n Other n Delta Depth of Grout Seat Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filter Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION I I DESTRUCTION [ (No septic system permitted if public sewer is ailable within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet!: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size t� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ � + i 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 Sart 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 of 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 ust call fo ll required i pections. Complete drawing on reverse side. Signed X jrl(�, Or�A Title: Date- FOR DEPARTMENT ate:FOR.DEPARTMENT USE ONLY J Application Accepted by Dates--/ 6 �Q —1 r �u 7 Area Pit or Grout Inspection by Date Final Inspection by r Date Additional Comments: Z90er a 7, 71-5 KS ❑ Stk 466-6781 ❑ Lodi 369-3621 Ll Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Enviror mental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEEO AMOUNT DUE AMOUNT REMITTED �R H RECEIVED BY DATE PERMIT'NO. r.EH 13-24 IREV.FiH5) EH 1426