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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 ' S py 'i t u City Lot Size Owner's Name J-0)tAJ 1�. PPQC Address _333 y` q,0J ! (�d`WCd.-t-:, Phone Contractor's Name License No. Phone 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Domestic/Private ❑ Public ❑ Irrigation Repair Work Done ❑ } Well Destruction ❑ Li upen tiottom ❑ Gravel Pack -t _❑ Other ---Approx. Depth Type of Pump Well Diameter Depth ❑ Manteca i Dia. of Well Excavation Dia. of Well Casing ❑ Tracy �. Type of Casing Specifications ❑ Delta Depth of Grout Seal Type of Grout ❑ Eastern Surface Seal Installed by H. P. State Work Done Sealing Material (top 50') Filler Material (Below 501 TYPE OF SEPTIQ WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residerice X Commercial _ Other s Number of living units: -4— Number of bedrooms 3 .Z Character of soil to a depth of 3 feet: C?./✓tl� Water table depth SEPTIC TANK ❑ Type/Mfg Capacity`No. Compartments PKG. TREATMENT PLT. ❑`' Method of Disposal Distance to nearest: Well Foundation T Property Line PM LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line s 9 SEEPAGE PITS Depth AW F Size _ '�i�/i{(', S' Number SUMPS Ll Distance to nearest: Well Foundation r} 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 fol31: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of CThe applicant all �requi�OjrApections. Complete drawing on reverse side. Signed X Title: 0WA-)9F<--c O'-- Date: FOR D /IP RT NT USE ONLY Rif � �T'Z�` �v.Gd2 Application L)by , `t �{F! / �Date Area Pit or Grout Inspection by Date Final Inspection by Date f Additional Comments: armly- dam-, `tk- 466-6781 t Lodi 369-3621 Manteca 823-71704 ❑ Tracy 8W636 �!/ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 IP/ FEE INFO AMOUNT DUE REMITTED CASH RECEIVED BY DATE PERMIT'NO. 1AMOUNT �11 ~1c1) ? q + EH 13-24 (REV. 10!831 EH 1426 Q� �` -I