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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 4' / ' 'z e City - Lot Sizes PM r 1 Owner's Nam J ,ie, Address 7 0� Phone Contractor LlCQ & Address 1+ Q.d)!fix '7/7 License No., 2 Z Z Phone l® TYPE OF WELL/PUMP: NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Di �, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES— — DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS � O 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 fl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P.:' State Work Done Well Destruction ❑ Well Diameter Seating Material (top 50') Depth I (Below 50'I �:f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION [ArlNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other • Number of living units: _/_ Number of be ooms } Character of soil to a depth of 3 feet: Water table depth r r y SEPTIC TANK Type/Mfg Capacity._._. No Compartments PKG. TREATMENT PLT. ❑ _ _ ._ �t Method of Disvosal Distance to nearest: Wetl= * T . � Foundation� Property Lin %e LEACHING LINE No. & Length of lines / Total length/size 410 X0 FILTER BED ❑ Distance to nearest: Well i Foundation Property Line SEEPAGE PITS Depth Size r Number r SUMPS L1 Distance to nearest: Well/D�� Foundation 1�! _ _ Property Line E . DISPOSAL PONDS ❑ 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 Di1tiict. Nome 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 mu �Ifr red ' spections. Complete drawing on reverse 1,e'd�axr (f�1Signed X ` Title:, , i► � Date:. i �— FOR DEPARTMENT USE ONLY 'Application Accepted by Date Area '1t or Grout Inspection by Dao Final Inspection by - .c Dat llll Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 CI 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 CKRECEIVED BY DATE PERMIT'NO. INFO �/t CASH +.EH 13-2!tREV.1/A 5) /� �+^ EH 1l-Z6 /