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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mide 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 ��x'c+`L''2 City��a f�� tY Lot Size' PM Owner's Name � � � 2a- ' Address S6� � �kPhone Contra ctd;-'r .t-E'A> Q l Address PG �� /67 License No.31)�'7r`x�z Phone-3(4- 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing _ Q ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications S i'I Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation ___Approx. Depth I I Eastorn Surface Seal Installed by ---- Repair Work Done (I Type of Pump H.P. State Work Done Well Destruction i 1 Well Diameter Sealing Material (top 50'1 - - Depth _Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I IEPAIR ADDITION I -DESTRUCTION 1 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will servq" Residence Commercial_ Other Number of living units: —L— NumberApedro�ms -�3 Character of soil to a depth of 3 feet: /'J �ps��- Water table depth / SEPTIC TANK I.I Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. I_I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINEL Nif o. & Length of lines — Total length/size— FILTER BED Ll Distance to nearest: Well Foundation �� Property Line z SEEPAGE PITS V, Depth Size 3 Number — SUMPS I I Distance to nearest: Well �On ' Foundation�1Z_— Property Line .:s DISPOSAL PONDS 1i I hereby certify that 1 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 District. 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 applicant IVXIcall fora quer d inspections. Complete drawing on rovler�e e. Signed X } X Title: V z Date! FOR EPARTMENT USE ONLY ApplicationAccepted lty ` �f' �� Date -� Area CP tor Grout Inspection bye L _Date Final Inspection by � � ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO CASH . EH3-24 IREV.lin 51 I 1 -C. G� / EH 11 4.28 1. • u li C/"(y��-\/�