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k ' w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON 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. Jab Address _1--v 7 SIT l'IL527/C ZR 6110 AC- City Lot Size d l d P _ PM Owner's Name,.$,�Vo4J jd�R/,06." Address /5 Phone.Y6 k- JF1 Contractor's Name ✓a' f >E-gaNs License No. Phone le4l— 6 0 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 ❑ Public ❑ Other _ ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material IBelo 50`} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence_ .Commercial_ Other Number of living units: __/-_ Number of bedrooms 2- t Character of soil to a depth of 3 feet: C 4 19 Water table depth SEPTIC TANK El e/Mf YP 9i� Capacity No. Compartments PKG. TREATMENT PLT. ❑ + � _ � Method of Disposal /Distance to nearest: Well Foundation Property Line LEACHING LINE ltd' No. & Length of.lines., Total length/size 2 2 FILTER BED ❑ Distance to nearest: Well_._.2 Foundation 1D Property Line SEEPAGE PITS ❑ Depth �� Size Vim' Number— f SUMPS ❑ Distance to nearest: Well ` � Foundation �0 ,,Property Line_ S DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and tha the work will be done in accordance with San Joaquin county ordinances, state laws, an� 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 pertor-mance of-the work for which this permit is issued, I shall npt(__ employ.any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signat e V 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 applican ust call for all required inspect' s. Complete drawing on revers si Signed: - Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area o 3 Pit or Grout Inspection by Date Final Inspection by Date Additional Comment . ❑ 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 4 INFO CASH RECEIVED BY DATE PERMIT'N0. + EH 241REV. 101831 W EH 1426 1