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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 Ryles and Regulations of the San Joaquin Local Health District. F• �� i / Job Address �- r- u7�l.Z.Q�r�� I rCity �ZA'12'G'A- Lot Size J PM Owner's Name 6iARS1 Address Aa' e�.�D --.-.Phone Contractor 4" �C��t�'Address 12License No. ��6'��fO�_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS) ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing u 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 9 Well Destruction ❑ Well Diameter Sealing Material (top 501 ' Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONY DESTRU,CTION,E] 'INb septic system permitted if public sewer is f} # available within 200 feet.) i Installation will serve: Residence Commercial_ Other < r � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1' s. Water table.depth SEPTIC TANK t Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f F Method of Disposal Distance to nearest--: WeII- ',� Foundation Property Line 20 , LEACHING LINE 6 Length of lines � � '' � � Total length/size FILTER BED ❑ Distance to nearest, - Well. :'—Foundation f Pfoperty Line SEEPAGE PITS ❑ Depth '' Size �`" ''" �' Number } SUMPS ❑ Distance to nearest: `_dwell, Foundation Property Line DISPOSAL PONDS 11-1 k 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 agents 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." I _ The applicant must call for II regquu'ed inssppections. Co plete drawing-on reverse side. Signed X � ,d,( A - Title: - �� Date: " FOR DEPARTMENT USE ONLY / Application Accepted b Date r z— d Area Pit or Grout Inspect n Date Final Inspection by Date Z� Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE i INFO`- AMOUNT,DUE ,,.,AMOUNT,REMITTED. CASH RECEIVED BY, ,-... f-DATE__ _PERMIT`NO.: +EH 1324 tREV.s/a$I EH 14-26