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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. 1852 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. / f� Job Address 7 LCity c rT Lot Size 7� CL L� RC2 PM Owner's Name �C`-7�_ Address 7 �trl(' C �L' G 'sc /cs'� _ Phone Contracio 1 {� L!t �!( (' Address A`z'z - ZZ License No. � Phone TYPE OF WELL/PUMP: NEW WELL 5 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ HER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS D. PROP, LINE FOUNDATION _ AGRICULTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA �CONSTRiN SPECIFICATIONS ❑ Industrial f I Open Bottom [-I Manteca Dia. YWeil Excavation _ Dia. of Well Casing __- Li Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing_ Specifications i Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout 1 I Irrigation Approx. Depth I ].Ea"stern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction L1 Well Diameter Sealing Material flop 501 Dept Filler Material (Below 50'} _ y TYPE OF SEPTIC WORK EW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _k Commercial— Other Number of living units: —I-- Number of bedrooms 1� _ r Character of soil to a depth of 3 feet:thT �d—llCI�C,.e�4-ext rri Water table depth _t?e _ SEPTIC TANK [Ai el Mf Cz��t C_�x��-'� ({� Yp 9 �.w Capacity L'1 No. Compartments Pi TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well � (' Foundation ._ Property Line LEACHING LINEis NT o. & Length of lines t° l Total length/sized'_ X 2— FILTER FILTER BED LI Distance to nearest: Well Foundation L�" Property Line b SEEPAGE PITS [ I Depth Size Number ' SUMPS fl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS LI 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 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 must call or all required insprfctigns. Complete drawing on reverse side. Signed X l Title: ' ' 'r �- Date: FOR DEPAR MENT USE ONLY Application Accepted by f _ Date 11_ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1641 E, Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE' INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. EK 13 (REV.I:M5) EH 14.2 G v/\ � Sri -1 ef