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APPLICATION`ri R SRMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT w 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 c Local Health District. -� Job Address City ZZ2rJ Lot Size SC S PM'� I Z? k : Owner's Name _ Apddress Phone ` Contractor Address License No. Phone i K ` 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 I 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 ` r ❑ Domestic/Private ❑ Gravel Pack ❑ Traby Type of Casing Specifications = ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done CIO I Well Destruction ❑ Well Diameter Sealing Material hop 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i k available within 200 feet.) - ` Installation will serve: Residence X Commercial— Other Number of living units: / Number of bedrooms 42 ' Character of soil to a depth of 3 feet: ZI-J11.7 Water table depth` 1 ! SEPTIC TANK 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal -� �� Distance to nearest: Well ��,� Foundation Property Line 15?7 r LEACHING LINE No. & Length of lines @ !yam `Tota! length/size P4 { ++ FILTER BED ❑ Distance to nearest: Well ZZ-45;_ Foundation /,2 r Property Line f SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line y DISPOSAL PONbs ❑ f 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 I F" employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature t3 } 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 ca�lll for all required inspections. Complete drawing on reverse side. ' Signed X Title: Gi 9 ,/�s�- —----- Date- I FO DEPARTMENT USE ONLY _ application Accepted by Date "�J Area ? 94spection by s A-41- ate � incl Inspection by Date S �� s � i Additional Comments: 5 ID Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 EJ Tracy 835-6.385 Applicant- Return all copies to: Environmental Ffealtlh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 FEE} j INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. EH 13-24�� EH 14-261REY,i/a