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APPLICATION FOR PERMITFj` '' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELION AVE., STOCKTON, CA Telephone Q09) 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 k [ Local Health District, 1 / StS !!i Job Address 4/40; LJ Cit �� ' Lot Size l PM Owner's Name -lz�L ` Address Phone / 7 ContracuCkrte Address C� �' License No�� Phone>� 'S�C1 F, 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industria$ ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications � t'1 Public Cl Other F1 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 50') Depth Filler Material IBelow 501 j TYPE OF SEPTIC WORK: NEW INSTALLATION Y%fl.i'AIRIADDITION I I DESTRUCTION-I 1 INo septic system permitted if public sewer is I ✓/ available within 200 feet.) l Installation will serve: Residence_ Commercial_ ther / Number of living units: _ ._ Number of b rooms Character of soil to a depth of 3 feet: Water table depth G SEPTIC.TANK Type/Mfg Capacity No. Compartments r 1 PKG. TREATMENT PLI/0- // Methodiof Dial FFF Distance to nearest: Well Foundation_.-- Property Line LEACHING LINE o. & Length of lines ��9�qyqv�datioi To)al lengtWsiie FILTER RED ❑ Distance to nearest: Wap _:__— Property Line ` SEEPAGE PITSDepth Size f11urr1bar SUMPS ❑ -Distance to nearest: Well f 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 rules and regulations of the San Joaquin Local Health Di§trict. 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, 1 shall not i 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 mu II for allgrelons. Complete drawing on reverse siidevSignedr Title: ►/�1 / Date FOR DEPARTMENT USE ONLY f� Application Accepted by - Date Area for Grout Inspection by 'Final Inspection by ` Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca `823>7104 ❑ Tracy 835-6386 - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO 1F +.EH13-241R EH EY-r/n5S t4-2B