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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ICOmplete 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 .133!?a E. 77kA,Y 4204-0AIX RD City aLoD! Lot Size /G?X Z,'/ PM QCrtl _DaI301 S Sl_ - i 1 7;P- Owner's Name Address Phone Contractor E"Y.;,;" WO-Orb Address "7�d•Ab��lSG�1r` A1/4 License No. J S 7b Phone 154r-377/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 M Public ❑ Other 17 Delta Depth of Grout Seal Type of Grout i I Irri4lation _-Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION I I DESTRUCTION I i lNo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_-Z Commercial_ Other Number of living units: _ Number of bedrooms.3 /f., 5 Character of soil to a depth of 3 feet: 4AY -nlirtSK9 Water table depth SEPTIC TANK El Type/Mfg [_ CapaCtty ` No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well_ZO-0 Foundation f0 Property Line "a f LEACHING LINE IST No. & Length of lines _ - Total.length/-' FILTER FILTER BED ❑ Distance to clearest: Well Foundation 10f Property Line or _ SEEPAGE PITS 114-'Depth _ .�1P Size= Numbe; SUMPS Ll Distance to nearest: Well�..5.!r Foundation �� Property Line DISPOSAL PONDS ❑ 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 required inssppections. Complete drawing on reverse side. Signed X Title: & Date: ARDEP, RTME USE_ ONLY Application Accepted by Date Q rea �� Pit or Grout Inspection by Date Final inspection by 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 2005, Stk., CA 95201 FEE 11 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. 13+,EH 13-241REV.v/x51 ,10 r EH 14-26 2r �