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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA i` Telephone (209) 466-6781 I 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., / ccc 1 Job Address�5�5 5 �J-FLt Llt tni [' ��?""'�"6 City� 4 Lot Sizel?;7317el y `��PM Owner's Namu e Address 7 0 V 2".1 4, hone r a x. Contractor • rr�cP�� 741� Ll Address 7 lo'F /? vvc- License No.-3 2 8 22� Phone_ TYPE OF WELT./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DES CTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - D OSAL FLD. PROP. LINE 1[ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS` INTENDED USE TYPE OF WELL PROBLEM AREA CON5TAGCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑•Gravel Pack ❑.Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ D Depth of Grout Seal Type of Grout _ I I Irrigation _.Approx. Depth- Eastern Surface Seal Installed by _ Repair Work Done "LI Type of Pump H.P, State Work Done , f ,l N Well Destruction ❑1 Well Diam Sealing Material (top 50'1 i� Dept = Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is tt�,► available within 200 feet.) Installation will serve: Residence X i( Commercial Other — Number of living units: _.__.�_._ Number of bedrooms Character of soil toga de�pt/h of 3 feet Water table depth SEPTIC TANK dr Type/Mfg e _� Capacity/,.n � No. Compartments PKG. TREATMENT PLT. ❑ I x Method of Disposal r Distance to nearest: Well eo Foundation `S Property Line $ r LEACHING LINE Iti No. & Length of lines ��• Total-length/size r r FILTER BED ❑ Distance to nearest: Well I o C foundation j L r Property Line SEEPAGE PITS 11 Depth { Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �--�` -^ h 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, l 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: "1 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 must call for all required inspections. Complete drawing on reverse side. Signed X JL.—A Title: Date: R DEPARTMENT USE ONLY Application Accepted by Daterea Pit or Grout Inspection by Date Final Inspection by � ate 17 Additional Comments! ❑ Stk 466-6 !l ❑ Lodi 369-3621 - ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return alk copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE .I INFO AMOUNT DUE AMOUNT REMITTED- CASH RECEIVED BY DATE PERMIT'NO. i - +.EH13 H t2A Eo-26