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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 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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. Job Address Lot Size 0A-f,. PM e Owner's Name tt! Address - Phone Contractor Address License No.c7rJC�7/� Phon fera 6-" 3� TYPE OF WELL/pump: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NE REST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i. 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 FlOther F1 Delta • Depth of Grout Seal Type of Grout I Depth i I Eastern Surface Seal Installed by I I Irrigation --Approx. i> . Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction j ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') -- x TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Ll DESTRUCTION f I (No septic system permitted if Public sewer is # L� available within 200 feet.) E Installation will serve: Residence_ Commercial Other Number of livin 'units: Number f bedrgotns 9' �� Character of soil xo a depth of 3 feet: Water table depth SEPTIC TANK 12rType/Mfg V Capacity—&470! No. Compartments PKG. TREATMENT!PLT.❑ � Method of Disposal i Distance to nearest: Well Foundation��1 Property Line d r Total len th/size 1 LEACHING LINE W1 O. & Length of lines ! g dry FILTER BED ❑ Distance to nearest: Well F� r Foundation�s r Property Line i SEEPAGE PITS 11 Depth SizeNumber SUMPS 0 Distance to nearest: Well �(4-)Foundation Property Line i DISPOSAL PONDS ❑ t i I hereby certify tha I have prepared this application and that the work will be done in accordance with San Joaquin county ordina9ces, state laws, and ! rules and regulatio?1s of the San Joaquin Local Health District. Home owner or licnsed agent's signature certifies the following: "I c6rtif> 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." Contractors hiring or sub-contracting signature certifies the fotlowi g:"I certify that in the performance of the work far which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califo la." 1 The applicant muscall for all require ins ctions. Complete dralniing on reverse side. w r Signed'X Title: �Wi1t Date: FO,R;-DEPARTIiIIEfilT1 USE'dN4Y r.' i Date ^� Area �� Application Accepted by v$ Pit or Grout Inspec'ltion by Date' ,_ Final Inspection by I Date Additional Comm4ts: ❑ Stk 466-6781 i ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/SeNiOps 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201_ FEE AMOUNT DUE AMOUNT REMITTED`' CK RECEIVED BY DATE PERMIT NO. INFO CASH +-EH 13-241REV.1/a 51 EH 14-26 �-�1