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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA '. Telephone (209) 466-6781 PERMIT EXPIRES 11-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. i - Job Address Lot Size 1 DomPM Owner's Name • N�`J 7 Address Phone Contractor Address {!i� ✓&A 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 E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Oen Bottom ❑ Manteca anteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ElGravel Pack ElTracy Type of Casing Specifications 1-1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _. �+ { I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filter Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 1< Commercial_ Other \\\\ I T Number of living units: _L_, Number of bedrooms �} Character of soil to a depth of 3 feet: Water table depth r ` SEPTIC TANK ❑ Type/Mfg Capacity/o_�W No. Compartments ' PKG. TREATMENT PLT. ❑ F* 7 Method of Disposal w Distance to nearest: Well-�— Foundations Property Line _ r LEACHING LINE No. & Length of lines —"lf« Total length/size d 1tf- FILTER BED ❑ Distance to nearest: Well C d Foundation I'7' Property Line ` SEEPAGE PITS I 1 Depth Size _ Number SUMPS ❑ Distance to nearest: Well 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 5 rules and regulations of the San Joaquin Local Health District. y 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: "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." I The applicant must call for all quire inspect, Complete drawing on reverse side. Signed X - t ` •� ^-' _ Title: e.4.-;�y+r/ bate: �p r F ARTMENT USE ONLY i Application Accepted by Date7-7-5___-JP Area { j Pit or Grout Inspection by Date Final Inspection by Dat-7 Additional Comments: i ❑ 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 F. FEE INFO AMOUNT DU_ E AMOUNT REMITTED . CK RECEIVED BY DATE PERMIT-NO, EH 13-24 IREV.i/n 51 EH 1428 7 r