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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 4_—_ALocal Health District. �� Job Address ! -7. Lot Size / ' PM Owner's Name Wetay.." � Address� / � Re e_ Phone O Z zA;za . ,5-/ � ,�os�1-f G 3 33 Contractor Address e' License No. Phone TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ • SYSTEM REPAIR ❑ OTHER ❑ 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 i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing D Domestic/Pfivate--t:_0 Gravel Pack ❑ Tracy' Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ l I I Irrigation Approx. Depth I I East n Surface Seal Installed by _ a Repair Work Done ❑ ;Type of Pump / H.P. State Work Done Well Destruction ❑ :.Well Diameter Sealing-Material Itop 501 --. Depth --"- = Filler-Material (Below 501 - �r TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION WDESTRUCTION l i (No septic system permitted it public sewer is [� available within 200 feet.) \_ Installation will serve: Residences Commercial Other Number of living units7 60 Number of bedrooms Character of soil to a depth of 3 feet: 620, Le,04 en _Water table depth SEPTIC TANK ❑ Type/Mfg Capacity D jF �D6 No. Compartments IQ- PkG. TREATMENT PLT. Method of Disposal Distance to nearest: Well Fou .ndation . Jl Property Line , � dv LEACHING LINE ❑ No- & Length of lines Total length/size FILTER'BED ❑ Distance to nearest: Well Foundation, Property Line SEEPAGE PITS Depth ?s7 I -Size Number SUMPS Q Distance to nearest: Well 1K.282.1 Foundation .—V—Of- Property Line s� z 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 Di%trict. 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." 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,1 shall employ persons subject to workman's compensa- tion iawsi of California." The applicant must call for all squired inspections. Complete drawing on reverse side. ,. Signed X- /J Title: -_�Gf1.UtC � Data: 1_ FOR R DEPARTMENT USE ONLY + A plication Accepted by Date r Q^ Area A. Pit or Grout Inspection by r Oats r Final Inspection by /' ate Additional Comments: " a U {d C] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 .+ i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT' NO. +.EH 13-241REV.�iHsf � /—7L.! EH 14-28 fi