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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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address -�55-� I � ,[__.�� City Lot Size Z / PM 9S-a37Owner's Nameliz�el Address o®. 2Phone 7a 7 a Contract Address Pa d ],02( 16-7 i�L 1—License NL5QQ2G Phone Cts?"S 1OS 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 �w FOUNDATION AGRICULTURE WELL _—OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca•r "'Dia.of Well Excavation Dia. of Well Casing' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of'Casing Specifications ; (1 ❑ Public ❑ Other E3-Delta Depth of Grout Seal Type of Grout 4a ❑ Irrigation --Approx. Depth ❑ Eastern V Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing,Material Itop,-50') '' Depth -(ler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI ADDITION DESTRUCTION'❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence r Commercial_ Other Number of living units: L_ Number of droorr Character of soil to a depth of 3 feet: �'''� Water table depth lao � SEPTIC TANK Type/Mfg J Capacity_/Ali7 Q No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well 150 ' Foundation '45 Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE-PITS ❑ Depth Size Number �y SUMPS ❑ Distance-toy nearest: Well Foundation 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."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." The applicant m t call for II required inspections. Complete drawing on reverse de. �f Q Signed Title: v� R� Date: ! O FOR DEPARTMENT USE ONLY Z/f Application Accepted by Date Area EIZJPit or Grout Inspection bye. Date Final Inspection by44 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi369-3621 ElManteca 823-7104 ❑ Tracy 8361-63E35 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 CK RECEIVED BY DATE PERMIT"NO. I INFO CASH +SEH 13-241REV.1/851 EH 14-26