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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL i 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. T�H� ��{ City 7'J! Lot Size PM Job Address �+ t7 Owner's Name _ C1/��%A/ F�Y.yi�/ Address ly/v/ fre,- /7r�l k� Phone 01(_5.rAy kContractor 50& Address RBLuC �� License Na.i '`' �� Phone fX �y�iy 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 t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t Specifications ' 17 Public ❑ Other Cl Delta Depth of Grout Seal I Type of Grout —.-- I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by A Repair Work Done 0 Type 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 11 REPAIR/ADDITION X -DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_L_ Commercial— Other r '' t Number of living units: j Number of bedrooms 3 Character of soil to a depth of 3 feet: �CL9Y "Water table depth /4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y r g PKG. TREATMENT PLT. ❑ f �f- Method of Disposal Distance to nearest: Wellc� Foundation Property Line r ' LEACHING LINE 21 No. & Length of lines 4OW-70 Total length/size x O FILTER BED ❑ Distance to nearest: Well (ROS_ Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ -... . ;' — T I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state law ` rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this petmit 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." .' e. The:ppitcant mus call for all required inspections. Complete drawing onreverseside-.Signd X Title: Data: / gd 4FOR DEPARTMENT USE ONLY, C Application Accepted by ' Date Z Area r C Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 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 20W, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO '�Win-.�•.. ` I C� {i ;� +7 . EH13-241REV.I/N5) 70- EH 14-26