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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 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.. / '�j� 1// �/ Job Address .2 / .SCS // ,n t(JC�4 �/ Y City Lot Size G/41f, PM Owner's Name G1� � /L>a[41 Address Phone ge 25-2 /Z/` Address (�C�] ;3D� �� Contractor License No. Phone 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type.of Casing Specifications FI Public n Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ 4 _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below, 50 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) p 1� Installation will serve: Residence i__Commercial_`,Other ' Number of living units: Number off�bpfdrooms' �� Character of soil to a depth of 3 feet: _Sd�a++ c'� Water table depth _ SEPTIC TANK LPI Type/Mfg 6k;i of 6 Capacity No. Compartments 2- PKG. TREATMENT PLT. ❑ i Method of Disposal \\ Distance to nearest: Well QQ Foundation �c ( Property Line .3 LEACHING LINE Est' No. & Length of lines © Total length/size f FILTER BED ❑ Distance to nearest: WellL Ap I Foundation f Property Line 3 SEEPAGE PITS ItV Depth of S Size r' Number 3 ? SUMPS Ll Distance to nearest: Well Foundation Property Line J 1 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 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.1his 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 must call for all required s�pe t-ions. Complete drawing on reverse side. ` Qq Signed X �// .� '�^'�/ Title: &Co4liCLP Date: FOR DEPARTMENT USE ONLY 2 Application Accepted by G Date F Area / y or Grout Inspection by Date Final Ins� � pection b Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 O 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 w IFEE NFO AMOUNT DUE AMOUNT REMITTED \.ASH RECEIVED BY DATE PERMI -ND. EH 13 24 linst 77-) EH 1426