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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. / 1 t Job Address�.4 Lot S-! P^tee! City & Lot Size Z:Pfr- PM s Owner's Name �{«V >QXC4 '.b Address 141NO Z4tG1Z1Y'11-A— Phone I Contractor Address License No. Phone TYPE OF WELL/P P: 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 11 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications f f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ ! Repair Work pone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') j Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is !• available within 200 feet.) 1 Installation will serve: Residence �V Commercial_ Other Number of living units: _*j Number of bedrooms 1 o Character of soil to a depth of 3 feet: Water table depth f 20 'I SEPTIC TANK ❑ Type/Mfg '1�'i'G-f Capacity fib 4) No. Compartments _r^ PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation (97 Property Line 3190 LEACHING LINE IW�Ncr. & Length of lines z"' Total length/size two �I FILTER BED ❑ Distance to nearest: Well Zia Foundation &d Property Line ypG �I SEEPAGE PITS I I Depth 2 Size 3 4 f Number Ll „,, 'Z— SUMPS Distance to nearest: Well T r� Foundation� Property Line J DISPOSAL PONDS O 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 Di§trict. ( Home owner of 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.”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 Calif nia." The applicant tp t call farelhequire "ct s. Complete drawing on reverse side. Signed / \lt/ Title: w N b'R- Date:If t Z' $ tippR DEPARTMENT USE ONLY ( Application Accepted by ��,(�/�WA Date F2�� Area t7 > Pit or Grout Inspection by ate Final Inspection by / Additional Comments: • ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823.7104 O Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t INFO AddMOUNT DUE AMOUNT REMITTED nCASrH y�RECEI�V9EED BY DATE �) P/Er�R,MIIYNO. r.EH 11241REV.1r H! EH 14M G