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APPLICATION FOR PERMIT 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / f Job Address &1 !6 /, City 04 Lot Size PM Owner's Name &44a6decAddress f!7! "�' ��`-�' ' Phone Contracto Z Address t .�� V 6W� tJ��U"�r License No. 3 ZV2Z& Phon311W-S � TYPE OFWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ElPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �' . I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS h INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing + � ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications ; t F] Public IF Other Ll Delta Depth of Grout Seal Type of Grout f i I Irrigation 1�.°' 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 501 Depth ler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1REPAIR ADDITION DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.] AN, _ Installation will serve: Residence -V- Commercial_ Other Y (� Number of living units: —Li Numberdroorrt Character of soil to a depth of 3 feet: _ 1 Water table depth ,,. .- SEPTIC TANK EI Type/Mfg ^ f 1 Capacity No. Compartments..' A 1 .� PKG. TREATMENT PLT. ❑ -�,,�,f `"� r'� f Method of Dispose! Distance to nearest: Well .. Foundation Property Line { LEACHING LINE >I� No-&Length of lines I Total length/size 1,16, x FILTER BED ❑ Distance to nearest: Wel! X70- - Foundation 10 Property Line r SEEPAGE: PITS X Depth ka, Size Number i < SUMPS Ll Distance to nearest f Well �� - Foundation -�� Property Line DISPOSAL PONDS 17 t I hereby certify that I have prepared this application and thatthe work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Jbaqu�n Local Heafth 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 fallowing: "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." 1 The applicantcall for a ui d.inspections. Complete drawing on reverse si Signed Title: T1, D ate: " FOR DEP RTMENT USE ONLY Application Accepted by �- Date Area � r r Grout Inspection by ate � inal.Inspection by� te/ Additional Comments: T k - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .� , Applicant - Return all copies to: Environmental Health Petmit/Services 1601 E. Hazelton Ave., P.O. Box 2609,:Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH a.EH 13-24(REV. /n 51 EH 14-28