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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Job Address _ �' "�'-' �� City rf!e _ Lot Size /Q PM // Address f4f��r? GO�f_4£hone c�3J" Owner's Name _ ' Address C'` License No��s�-� _Phone 465LE Contractor e2i Vol TYPE OF WELL/PUMP: J NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENIDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom I] Manteca Dia. of Wel{ Excavation Dia. of Well Casing 3 j- <r Type of Casing Specifications ❑ Domestic/Prl�ate' C ;Gravel Pack ❑ Tracy yp 9 l'l Public f I] Othe Cl Delta Depth of Grout Seal Type of Grput I Irrigation _Approx. Depth l l Eastern Surface Seal Installed by _ Repair Work Done LlType of Pump H p State Work Done ! Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 - TYPE OF;SEPTIC WORK: NEW INSTALLATION b-'REPAIR/ADDITION l I DESTRUCTION I I INo sbetic system m rented if public sewer is Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms- q __ 'k*' ��m Water table depth Character of sail to a depth of 3 feet'. t/-,.,,,,, 2 f SEPTIC TANK ®Type/Mfg CISw .t t�f>>-. � Capacity— — No. Compartments jY Y PKG. TREATMENT PLT. ❑ Method of Disposal n r r t Distance to nearest: Well Foundation��- Property Line ' r _� Total length/size LEACHING LINE CA�No. & L•engtK_��lines FILTER BED ❑ Distanceear`es't:� Well_...! _ Foundation o7 Property Line d SEEPAGE PITS lyl" Depth a S ie�� ri _`\ Number{ y �� d f SUMPS ' ❑ Distance to nearest: Well�-~--Foundation_ r�operty Line j DISPOSAiL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done n accordance with San Joaquin county ordinances,state laws, and rules and'regulations of the San Joaquin Local Health District. ""f=I-�—e i 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." Contractors 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 all requir d ins ctions. Complete drawing on reverse side. ] Signed XI Title: 6 ajoe_�( Date: i FOR DEPARTMENT USE ONLY I Date �7(J Area Z Applicati'n Accepted by it Inspection by G Date Final Inspection by - Al Additional Comments: I ❑ Sik 466-6781 ❑ Lodi 369-3621' ❑ 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 AMOUNT DUE AMOUNT REMITTED ~ YCK RECEIVED BY DATE PERMIT NO. 1 INFO CASH G +.EH 13-24 MEV.t/K5) �b0 �LS/ e o 92—97)_ EH 14-2a