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APPLICATION FOR PERMIT 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 7� / ��"�/G City `"�r� '''Lot Size PM Owner's Name �� ` `mom Address Phone Contractor . t rt� -`.�-- - Address_2),50 LAD` gn8 License No. 30 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 ❑ Industr`ial 0:Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I;P Public Cl Other+ ' ❑ Delta Depth of Grout Seal Type of Grout =`I I Irrigation '_Approx. Depth { I Eastern Surface Seal Installed by s Repair Work--Dane ❑ . Type of.Pur>of H.P. State Work Done t Well Destruction C Well Diameter, Sealing Material (top 501 Depth--, Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I:.—fMV_AIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:/Residence_L-:`�Commerciai Other Number of living units: _L_ Number-of bedrooms ' Character'o!,s ro I to a depth of 3 feet:± f � C \! A Water table depth SEPTIC TANK ❑ Type/Mfg; `„10A_.IC-r- Capacity-_,_P 2�-� No. Compartments PKG. TREATMENT PLT. Cl t l � "`7 p e � Method of p' p a Distance to nearest: -Well _ Foundation Property Line / 1 ' r LEACHING LINE . & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well�Q Foundation Property Line a I , I, SEEPAGE,PITS %U/Depth Size Num er SUMPS Ll Distance to nearest: eWell Foundation� Property Line DISPOSAL PONDS ❑ I 7 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 Joaquiri, Local Health Diltrict. ' ' 1 ',* . 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 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 lifornia." 1 The applicant mu 11 fora re ed i pection t drawing on r erse side. Signed X Title: ( Date: D j FOR DEPARTMENT USE ONLY a Application Accepted by Date a Area Pit or Grout Inspection by Date�� ' Final Inspection b Date 1 a,..r..�...—.-.. -.....,...._�.,..-. ..--...�.�..�-.ter.-s�_.,_.�-�-._.._._ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 . Applicant - Return all copies to: Environfinental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20D9, Stk., CA 95201 i �" FEE— AMOUNT DUE'r A�MOUNTJREMITTED r RECEIVED BY DATE PEttMIT NO. INFO _ +.EH 13-24(REV.1 i x s) EH 1429