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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR 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 " t t t City-M-1701''ee-ALot Size�� PM Owner's Name � e Address Phone Contractor ! �+ u�(�,1 Address_ 1'Q �QX', �'f License No. Phone TYPE OF WELL/PUMP:_ NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i 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 ! ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - h i I Irrigation _.-Approx. Depth ( I Eastern Surface Seal Installed by 1v�1 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION kor REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 3 Character of soil Ida dept of 3 feet: S,*i&Ot 7u `&Ott _Water table depth SEPTIC TANK li Type/Mfg P*:)- Cy)AC4-&+r., Capacity No. Compartments. PKG. TREATMENT PLT. ❑ l Method of Dispoal Distance to nearest: —Well �+�D Foundati.h'. Property Line LEACHING LINE kYrNo. & Length of lines_ —7)6 ~ Total length/size A40 + ^ FILTER SED ❑ Distance to nearest: Well Foundation_/L?� Property Line 300 SEEPAGE PITS; i I- Depth.,-s"'? - Size Number SUMPS ❑ Distance_to.-nearest:. Well 4_Fiiuridation Property-Line r DISPOSAL PONDS ❑ F. hereby certify that I have prepared this)application and that the work will be done in accordance with San Joaquin cbunty 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 became.subject to workman's compensetior,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 of California." The applicant must call for all req' inspections. Complete drawing on reverse side. Signed X /'^'� -- Title: N/-,�- Date: FOR EPARTMENT USE ONLY _ / r Application Accepted by Date 2- I � Area Pit or Grout Inspection by Date Final Inspection by &=11Q� Q,r__ Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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 FEE AMOUNT DUE AMOUNT REMITTED CK 9 RECEIVED BY DATE PERMIT'NO. INFO L/ CASH / yn t F, +.EH 3-24 IPEV. 970, 0� f !!� { �O �U� EH n , 14-28 tIllfff((( 66G CCCJJJ i',