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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) 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 _ l' Gjr City �{' Lot SU, PM Owner's Name - ee /J ? Address �/7�'' Phone. Contractors Name/ ,:r-; { { �:"'License No. . Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ I 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 Dia. of Well Excavation Dia. of Well Casing { ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Ea stem Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50 Depth Filler Material (Below 50'1 -�- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) { Installation will serve: Residence Commercial_ Other Number of living units:. Number of bedrooms _ I Character of soil to a depth of 3 feet: F-X + -7 ;1! `+ Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity Z.4;; No. Compartments PKG.TREATMENT PLT.❑ r �' Method of Disposal Distance to nearest: Well Foundation I U Property Line LEACHING LINE ( No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 7z Property Line �7� ` t r SEEPAGE PITS ❑ .'"Depth Size, .G� al i Number SUMS� ❑ Distance to nearest: Well Foundation n ,, L Property Line i`�t)1Sf'QSAL 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 District. Home owner or licensed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued,1 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 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 inspect!-an Complete drawing on reverse side. Signed X�� J !' ,rc�/.- Tide: Date: r FOR DEPARTMENT USE ONLY Application Accepted by s Date ^ Anja.. t� iPit or Grout Inspection by Dabs Final Inspection by ^ `� Dots i Additional Comments: 'r ❑ Stk 466-6781 ❑ Lodi 369-3621 ;❑ Manteca M3-7104 ❑Tracy 83546385 Applicant-Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMrr NO. INFO {EH 112 /REV.i0/83M 4. -31 r, e,I:) 4—