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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 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. �7 (/ Job Address City Go�� Lot Size _ C ��{ PM Owner's Name � _11-2 Address � 0) �' � L'`-0' Phone z�, Contractor/v!' 2/ Address I-WJ sra_r! led 001 License No. J0 f�7 1 Phone �6�jsj3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation__ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public h Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I 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 (Below 501 TYPE QF SEPTIC WORK: NEW INSTALLATION t.� REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: ( Number of bedrooms z__— Character of soil to a depth of 3 feet: _ f�3-G,Lz+ C o(� Water table depth SEPTIC TANK Type/Mfg _ & Capacity. No. Compartments 2- PKG. TREATMENT PLT. ❑ Method of Disposal ��y f i Distance to nearest: Well ��_� Foundation l� r Property Line _3�0 LEACHING LINE R' No. & Length of lines 2 �y Total length/size CPO FILTER BED ElDistance to nearest: Well r� s, Foundation / Property Line, �- SEEPAGE PITS ILV Depth _Q2_1� ..Size �] zz Number —` SUMPS Ll Distance to nearest: Well /�� f Foundation _Gpt�r Property Line s 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 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." The applicant must call r al required inspections. Complete drawing on reverse side. Idy Signed X_ - — Title: W�lz� Date: �� —l?�._i�- RTMENT USE ONLY Application Accepted by ` �� Date � Pit or Grout Inspection by Date Final Inspection by Date - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED eCC�ZS#H RECEIVED BY DATE PERMI7 NO. —��) /]FH t3-24(REV.1,n!,, V�� r� X I I�" — C. -7 'J)