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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 Local Health District. ' Job Address _f 7 I City Lot Size 02-0 g1 PM_ ` Owner's Name �r A49M Address itt Phone Contractor's Name gC•b License No. Phone31W_Jf.?�? 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 I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta bepth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50.1 Depth Material"(Beidw 60') -^ - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION.❑ (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence commercial— Other 7 f 1 Number of living units:---t— Number of bedrooms' Character of soil to a depth of 3 feet: e� Water table depth i I SEPTIC TANK P_r T FA � ect� a7 'L37) No.'Com artments 1 Type/Mfg. _Capacity p PKG. TREATMENT PLT. ❑ Method of-,Disposal tt Distance to nearest: Well Foundation �roperty.Line d 1 LEACHING LINE e--No. & Len gth of lin `rr�► � _ Total`length/size +ZQ f FILTER BED CYDistance toy nearest: Weii,a200 r Foundation Lk { I Firopefy'Linea ; I - I + i ' " k 3 ` SEEPAGE PITS CI-o"{Depth 4_�As� Size_R_� _ Numbers SUMPS ❑ Distance to.nearest: Well _ .Foundation t5 �'Property Line DISPOSAL PONDS ❑ 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. y J 4 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;4f-California.".Contractors hiring or sub contracting signature certifies the following: "I certify that in the7performance of the�ork,for which this permit is issued,I shall employ person`s subject to workman's compensa- tion laws of California." } ,A'— The applicant must call for all squired in c' s. omplete drawing on reverse side. off - F Signed X Title: Date: FOR DEPARTMEiNT`USE ONLYI,. r Application Accepted by y Date"10.1 " S Grout Inspection b,,,-/ ate Final Inspection by Date�f Additional Comments: a _ te ❑ Stk 466-6781 ❑ Lodi 3W3661 ❑ Manteca 823-7104 ❑�- racy-835-6385 <• } Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,StlkCA 95201 FEE INFO AMOUNT DUE �AMOUNT'REMITTED —CASH � RECEIVED BY"" _ DATE 'PERMIT NO. + E"1 3-24(REV.10/831 10 EN 1426 S C1 O ��a/sS �s S •� ,} ' � d