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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 00pl. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Tdiis application is IV �= 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. Job Address 4nC%:5 In � � L � City L Lot Size ' may= PM Owner's Name �n E"�]�Z 7 � ;/– `gddress �,r Phone C,�. f Contractor - Address � s i License N Phon TYPE OF WELL1PUhAP: NEW WELL © WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CI 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 n Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by d Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') a Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.) REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other t -- -..Number-of-living-units:-. --__-_Number_of-bedrooms_.--_—. _ `j Character of soil to a depth of 3 feet: Y Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No_ & Length of lines Total length/size FILTER BED ❑ Distance tone arest: Well Foundation Property Line SEEPAGE PITSYN Depth .4c__ Size_:��--'� Number SUMPS ❑ Distance to nearest: Well F_Z:?lQ Foundation-/ f Property Line /9� 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 I{ rules and regulations of the San Joaquin Local Health Diltrict. 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 shalt 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 for all required in tions. Complet drawing on reverse side. , Signed� Title: �- I& ---25 � Date.: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit Grou ��t Inspection b - Y Date Z Final Inspection by d,. Additional Comments: l ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 0 Tracy 835-6385 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 CK RECEIVED BY DATE PERMI7'NO. INFO �/�+ `1f CASH pG £H t4-2a EH 13-24(REV.Bina) Z 0 , t/�'!- to-�� `d`r