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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. { Job Address 4�.2-Ze G2 AA/r i et/�' City C Lot Size PM k P� ITe Address y�7 y �' �r L'v P lel . Phone Owner's Names' yt'_ — J{O Address Off, Gv' ---License [Vo�y �' Phane Contractor KrT TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic)Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — - ' T e of Grout I'1 Public 171 Other ❑ Delta:: Depth of Grout Seal I YP I 1 Irrigation __.Approx. Depth t Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. -' 'State Work Done Well Destruction ❑ Well Diameter Sealing Material ltop.50',1 Depth Filler Material (Below.501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR IADDITIONZ DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence1 Commercial__ Other Number of living units: __I-- Number of bedrooms —1 1 ; Character of soil to a depth of 3 feet: L°Ad� CSA _Water table depth ` i I SEPTIC TANK ❑ Type/Mfgt Capacity No. Compartments PKG. TREATMENT PLT. L1Method of Disposal '3 n_ Distance to nearest: Well Foundation 1 Property Line I LEACHING LINE No. & Length of lines 170 Total length/size XDOr ' FILTER BED ❑ Distance to nearest: Well e4O 4' Foundation. � --- !_Property Line ' - SEEPAGE PITS 1 ) Depth Size it Number j SUMPS L1Distance t_o nearest: Well Faundaiion Property Line DISPOSAL PONDS ❑ _ * ., - I hereby certify that I have prepared this application and that the vvork wf'1'15e`done in accordance with San Joaq'uiri cbuntylordinarices;"state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued;l shall employ persons subject to workman's compensa- tion laws of California." Thea licant mu t call for all required inspections. Complete"drawing on reverse side. 1 PP ,y f , i r '� t st s r 1 Date: Signed X Title:" FOR DEPARTMENT USE ONLY f! t_ Date' "^Area Application Accepted by f i . Date'A2 L 0 Pit or Grout Inspection by II'Date Final Inspection by ! Additional Comments: d vy. nd' Cor t �'�� a rn 6 E Ora r4e G� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 1 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO- d, +.EH13-241REV.1/H51 EH 14-26 111 1 —