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I i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMfT EXPIRES 1 YEAR FROM DATE ISSUED (Completo 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 wail/pump and the Ryles and Regulations of the Sen Joaquin Local Health District. Job Address x G� s ,!�_ -- Citi Lot Size r QPM owner's Name to �L��a� r?}z -Address Phone Contractor �_�� ^� Address_ /1 -r,�-C? License No.41 i-O5 Phone�- T_Y_PE OF_WELL/PUMP: NEW WELL fir WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER L] 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 SPECIFICATIONSt ❑industrial O Open Bottom ❑ Manteca Dia.of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack D Tracy Typo 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 _ Well Destruction ❑ Well Diameter Sealing Material(top 601 Depth __ Filler Material(Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION D DESTRUCTION❑ (No septic system permitted if public sewer is available within 200 feet.) G Installation will serve: Residence✓ Commorclei_ Other Number of living units:---I— Number of bedrooms .-2 Water table depth Character of soil to a depth of 3 feet: _ ate fn SEPTIC TANK Cl Type/Mfg Caoecily �45? No. Compartments V.l PKG. TREATMENT PLL 177 Method of Disposal Distance to nearest: Well_�Foundation_�� / Property Line . LEACHING UNE L] No. &Length of lines _ �ep Total length/size- FILTER SED D Distance to nearest: Well Foundation l Property Line � R SEEPAGE PITS ❑ Depth Size--- _ - - Number SUMPS U Distance to nearest: Well Foundation - Property Line'_ DISPOSAL PONDS ❑ �t I hereby certify that I have prepaied 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 perfgrmance 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,1 shall employ persons subject to workman's compensa- tion laws of California." ' The applica u t call rail equlred i tions. Complete drawing on reverse side. St- ____ Title: - �7 Dato: ! v FOR DEPARTMENT USE ONLY Application Accopted by __ Date - Area �-7j c/- Pit or Grout Inspection by Daie" _ T o Final Inspection by /; _ Date O Additional Comments: __.____ ❑ Stk 466-6781 n Lodi 369-3621 Cl 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 55201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH1424(REV.1/SO \ !^-)-