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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA J 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. Job Address 5y99 'City Lot Size � �� PM Owner's Name_//r�� Address54 �� ^ Phone 1S0 " -70 Cnntrac G� Address 't:�. d¢7 ,_ License No.Savaa(2 Phone �A-5�� 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 `PITS7SUMPS 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 11 Public n Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I l DESTRUCTION l I- (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Others Number of living units: Number of tedrooms Character of sail to a depth of 3 feet: Water table depth 7Q SEPTIC TANK 5� Type/Mfg Capacity=00 No. Compartments PKG. TREATMENT PLT. ❑ _ r r Method of Disposal ��Distance to nearest: Well 15p Foundation Property Line _ LEACHING LINE L� Na. & Length of lines f" yLo Total length/size Q x o? r 11 FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line_ 5 SEEPAGE PITS i I Depth ��`—� Size '{�� Number _ SUMPS LR-'Distance to nearest:,--T Well D t Foundation 14 c -Property Line DISPOSAL PONDS ❑ I hereby certify that l 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 taws 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 m�t :alior req�uiredpections. Complete drawing on reverse side. Signed X Title: 1/. I e Date: l $ �— FOR DEPARTMENT USE ONLY Application Accepted by Date T'27 Area r row Ifispection by ate •Final Inspection by Date �� 01, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95201 FEE CK 4 INFO AA�� AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦ EH 13.241REV.r/A51 /� EH 14-26 F