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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 City C" M Lot Size PM T � Address 7L/ Pi 4,z- 3� e-10 Owner Name tine Contractor Address 1r t 0,_rCC) License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST_ SEPTIC TANK, SEWER LINES ' 7' DISPOSAL FLD.' PROP-LINE - 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPEOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca i -Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (-I Public ❑ Other C"� Della:- Depth of Grout Seal Type of Grout I I Irrigation —'Approx. Depth l 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. E State Work Done Q 1 Weil Destruction ❑ Well Diameter Sealing Material (top50'I, v Depth Filler Material (Below 501IU TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is '! available within 200 feet.► +� Installation will serve: Residence_ CommercialOther Number of living units: Number of bedrooms - f ' Character of soil to a depth of 3 feet:. _ Water table depth SEPTIC TANK ' Type/Mfg Capacity � No. Compartments (� PKG. TREATMENT PLT. ❑ !! l Method of Disposal k7Jg1+(JV Distance to nearest: Well czz; foundation �� Propeine L, J IA Go LEACHING LINE No. & Length of lines 0 '� f otal length/size A FILTER BED ❑ Distance to nearest:" "W6II F4%4,- 4`3 Property Lin i SEEPAGE PITS Depth �� Size - �'. - 4" (Number SUMPS LI Distance to nearest: Wel! Foundation Property`Line . r DISPOSAL PONDS ❑ ni 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 i 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 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 folldviing: "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." - - = .- .• ._.� T The applicant must call for all raqui ppections Complete drawing on rev * sl a"= Signed ` "` " r - Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date d Area c R Pit or Grout Inspection by 1.4, Date s Final Inspection by Date IV Additional Comments: ❑ Stk 466-6781 ❑ Lodi I.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 n FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PE RM I T-NO. +.-EH 13"24(REV.t R 5) C, Ai EH 14-26 ((( C- IJU ✓/°�