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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 g PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) t1 -Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orinstall 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 !�� City S l �r r Lot Size PM Owner's Name --Y.9 IJ f—f Address V 1Y-kL t2q ilJ2 Phone 217 Contractor f Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR��OP.,�LIN6— _ FOUNDATION AGRICULTURE WELL OTHER ��WEL�r� - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTION-SPEC1FIWIONS r � a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.--6f-Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ElTracy "_.r"`Type of Casing t Specifications FI Public F) Other �✓'r.—`I 1'Delta Depth of Grout Seal Type of Grout—.. I I Irrigation _ Appro cam. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ pe of Pump H,P. State Work Done _ Well Destructi ❑ Well Diameter Sealing Material (top 501 ` n Depth Filler Material (Below 501 +�J' TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION 1.1 DESTRUCTI07 No 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: 42 Wafer table depth SEPTIC TANK Type/Mfg Z&Arrz Capacity No. Compartments I 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 SEEPAGE PITS I I Depth Size Number i SUMPS ❑ Distance to nearest: Welt Foundation 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 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." Th icant must`call f ail re/q�uired ins ctio Complete drawing on reverse side, t _ Signed X l/�` '/�. - Title: Date: ` 1 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inepectio b Date .Final Inspection by 4 Date �� I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Heafth 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 13-241REV.I/R 51 - U� � �UCS 2G �-C r , EH 14-28 [t C3 4