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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. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. w Job Address '^' e , r4 A/ � � l City .Lot Size PM Owner's Name Address Phone fAV 'V 1t3 Contractor�r! 4,3 s Address �✓U' 4`�'[7 ze `L'icehsq No. Phone TYPE OF`WELL/PUMP: —4 --NEW WELL-0 WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �`+: �.,.� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWEh' LINES - DISPOSAL FOLD. PROP. LINE r FOUNDATION "Y AGRICULTURE WELL OTHER'WELL.--`- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA--CONSTRUCTION.SPECIFICATIONS'----. ❑ Industrial ❑ Open Bottom' Y _ ❑ Man#eca r Dia. ofWellExcavation". %Diad of Well Casing ❑ Domestic/Private EJ Gravel Pack ❑ Tracy Type of Casing Specifications ' 1J Public ❑ Other " ❑ Alta' ��. 'Depth of Grout-Seal.- -- -- .--.• r� Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 4 Repair Work Done ❑ Type of Pump r H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelowj50')' i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.) C411 } Installation will serve: Residence:A— Commercial_ether - Number of living units:._ Number of.bedLpoms q Character of soil to a depth of 3 feet: '' S Gtr Water table depth ow I SEPTIC TANK i, 1 Type/Mfg S' Capacity 1-54ye No. Compartments 'L PKG. TREATMENT PLT. Ot / Method of Disposal , FDistance to nearest: Well 150 Foundation tfd Property Line �� LEACHING LINE 1 fNo. & Length of lines 410 Total length/size a FILTER BED ®-3 Distance to nearest: Well 00 Foundation -4 fd Property Line f I d } ! SEEPAGE PITS V Depth Number SUMPS * L Distance to nearest: Well Foundation 4-1,0 Property Line DISPOSAL PONDS ❑ ' �l hereby certify that I have prepared this application and-that-the work will be done in accordance with 5ar1'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 pdrformancesof the work'for-Vvhich 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus 4fr uComplete drawing on r rse side Signed _ ' Title: ! `s, Date: i� ry -.. FOR DEPARTIIAENT USE ONLY`" Application Accepted by C11 ,; k Date Area tl Pit or Grout Inspection by f" Date `�L7' Final Irispec#ion y Date' kz Additional Comments: I Stk x466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 pplicant- Return all copies to: Environmental Health Permit/Services 1601 E'Hazelton_Ave., P.07Boz 2009;8tk_ CA 95201FEE INFO AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 1324(REV.F/a5) EH 14-26 fl 6S A.%0 t