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APPLICATION FOR PERMIT 4 *. � ' T SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON'AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES TYEAR FROM DATE ISSUED r (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w4rk�herein des cribed.iVis 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°af the San Joaquin Local Health District. r Job Address S776/ O ree City' Size PM 4c;Owner's Name SII^ G�L-Y} e� Address 1 rL..A Pho /'}} �7 ~ Zb—a45 Contractor Address P40 X �� License No.I bZ 3 i 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OISPOSAL'FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 ❑ Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 3 � r 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s. 1-1 Public it Other 1 Cl Delta Depth of Grout Seal Type of Grout. I I Irrigation Approx. Depth I I E tarn Surf a Seal Installed by _ Repair Work Done Type of Pump H.P- State Work Done _ Well Destruction 0 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feed Installation will serve: Residence Commercial T Other '{ Number of living units: Number of bedrooms Character of.soil to a depth of 3 feet, 'Water table depth SEPTIC TANK 0 Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ _ �' Method of Disposal ` Distance to nearest: Well Foundation - 'Property Line LEACHING LINE Cl No. & Length of lines Total length/size 46 : t 't - FILTER BED .x'` . ❑ Distance to nearest: 'Well _ _ Foundation Property Line a k 'ti .•SEEP�4'E,PITS I'1 Depth I Size 1 _ f Number SUMPS t f Cl Distance to nearest: Well Foundation Property Line DISPOSAL-PONDS ❑ e 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 re ons o San Joaquin Local Health District. Home o er or licensed ag nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall-h'ot- emplo any person in such neer as tri b came " t subo workman's compensation laws of California."Contractor's hiring or sub-contracting signature certif' s the following: "I'c ify that in th In. ��)Ihwor hich t ermit is issued,1 shall employ persons subject to workman's compensa- tion aws of California.;'The pplicant 'us r all req i e let drawing o rev a side. Signe X Title: Date: DEPARTMENT USE ONLY " Application Accepted by Date � _,Area Pit or Grout Inspection by Date Final Inspection by Date,-/2—z Additional Comments: "�_1 0 Stk 466-6781 , / 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return allFcoples to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - FEE, AMOUNT DUE AM T R MITTED CK RECEIVED 8Y DATE PERMIT'NO. INFO _ CAS + EH 1324(REV.1/n 5) EH I