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APPLICATION FOR PERMIT I' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 4 Job Address 4-,/ 7 ZA4 i City Lot Size PM � y Owner's Name /` �R 5;1eplll� AddressPhone i Contractor !'/494 : N5 '� Address 8-1222 License No. 4rs,--j4�_ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 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 / L-] Industrial C1 Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing AF Domestic/Private ❑ Gravel Pacrk ❑ Tracy Type of Casing Specifications 1-1 Public f_1 Other F1 Delta Depth of Grout Seal Type ofr Gaut _ #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 Itop 50'1 Depth I Filler Material (Below 501 V TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I 1 INo septic system permitted if public sewer is available 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:f 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS l I Depth ---I - t ,. Size Number SUMPS ❑ Distance to nears t.4g4,, Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify,that.f have prepared_this.applicatianand 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. i Home owner or licensed agent's signature certifies the foflowing: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mariner-7 to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ' certifies the following: "I certify that iri 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 I or- require tiuni 'Complete drawing on reverse sl e. Signed X-- �. a -� �� w � g 'C'y - -Title: Date: ! I ' ,,,_FOR.DEPARTMENT USE ONLY i Application Accepted by r# Date Area Q.> Y w- !§Z- Pit or Grout Inspection by t ~J _ _ Date _ F�inal Inspection_by_-_ _ Date.J/—L-W— Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3� ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE r AMOUNT REMITTED CASH EH 4RECEIVED BY DATE PERMIT"NO. +.EH 1 -24(REV.1/nsl