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APPLICATION FOR PERMIT ,,.OtAN JOAQUIN LOCAL HEALTH DISTF`/f 1601 E. HAZELTON 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. Job Address 7�'3l yf e City Lot Size Jfi!" PM Owner's Name G/ Address Sr*-7-k" Phone p Contractor !-i• Address �— License No Phone O3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dla. of Well Excavation ❑ Domestic/Private El Gravel Pack Dia. of Well Casing ❑ Tracy Type of Casing f'1 Public U1 Other Specifications fications Depth of Grout Seal Type of Grout I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR.ADDITION DESTRUCTION I I INo septic system permitted if public sewer is Installation will serve: Residenceavailable within 200 feet.) / Commercial_ Other Number of living units: 1 Number of Character of soil to a depth of 3 feet: P ' SEPTIC TANKWater table depth ❑ Type/Mfg PKG- TREATMENT PLT. ElCapacity No. Compartments „l Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE 14*'No. & Length of lines $'p r 7 FILTER BED t Total length/size ❑ Distance to nearest: Well Foundation t 3Q / Property Line SEEPAGE PITS L0Depth �� I Size 3 SUMPS Number t^ \ Ll Distance to nearest: Well �7 r ` DISPOSAL PONDS ❑ Foundation n Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San T rules and regulations of the San Joaquin Local Health Di3trict. Joaquin county ordinances, state laws, and 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 applica mu all for all req ed in coons. Complete drawing on reverse side. Signed 2 Title: —!JL>LV,.I' Date: 7 FOR DEPARTMENT USE ONLY Application Accepted by !� 7 Date- Area Pit or Grout Inspection by Date 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.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE 'AMOUNT REMITTED C INFO ASH RECEIVED BY DATE PERMIT'NO. • EH13 24(REV.1/8 5�