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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. I �^ ,� [ / 4 Job Address nV3 _SCS l �� a✓� City �`+tU✓� Lot Size (._3�x 306- PM Owner's Nam ®� k� Address //��, I! J� V. �i b L1%SC '[CXL Phone Contractor Address — �b License No. _ ` � Phone TYPE OF WELL/PUMP: NEW WELL ❑ G WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:YSEPTIC_TANK �` SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL, PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications RZ F]'Pubiic ❑ Other ❑ Delta Depth of Grout Seal Type�of'Grout - 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 I Filler Material (Below 50') {, TYPE OF SEPTIC WORK: NEW INSTALLATION)i< REPAIRIADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is �t-/ I available within 200 feet.) Installation will serve: Residence-)!(— Commercial— Other — s ' Number of living units: —_/ — Number of bedrooms 2 r Ch atter of soil to a depth of 3 feet? P Water table depth SEPTIC TANK Type/Mfg city_ 09th No. Compartments PKG. TREATMENT PLT. ❑ r.= Method of Disposal ;Z1 Distance to nearest: Well ] 9 0 Foundation 1 " Property Lined �! LEACHING LINE I No. &.Length of lines FinC.iG_ Total length/size DC7 r✓ FILTER BED ❑ Distance to neargst: Well ®7 Foundation J Property Line ► / T I- SEEPAGE PITSepth Size Number SUMPS ista a to nearest: Well l(00 Foundation Propertrty.La-lt 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 rules and regulations of the San Joaquin Local Health District. ."J 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 Calif ia." The applicant u call for all re a nspections. Complete drawing on reverse side. 3 -J7f Signed X Title: �[��Q�� Date: FOR DEPARTMENT USE ONLY t Application Accepted by Date Area' Q) Pit or Grout Inspection by { Date Final Inspection by Date Additional Comments: ? Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ElTracy 835-6385 plicant - 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 K RECEIVED BY DATE PERMIT'NO. I r EH 13-24(REV.1/K sk EH 1028 - 70 -- - - I