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Y APPLICATION 1FOR PERMIT - SAN JOAQUIN RLOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Local Health District. Rules and Regulations of the San Joaquin Job Address City Lot Size 4C, `PM y/ Owner's Name ,Q� - ® F�t r /\ � CK��Jag = Address 717 '�"i Phone Contractor Address License No. Phone 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 —pKoBLENA A4REA`" CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private L-1GravelPack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other f ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 9 .---Approx. Depth i ❑.,Eastern � Surface Seal Installed by Repair Work Done LJ Type of Pump x H.P State Work Done_ Well Destruction ❑ Well Diameter #Sealing Material (top 50') Depth F G Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is --T ,,.. e,�- ""�-'" "' -- vailable within 200 feet-1 Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water_table.depthx SEPTIC TANK Type/Mfg Capacity Nol Gompartrnents PKG. TREATMENT PI l7 1 - Method sp sa of Di ' Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED E] Distance to nearest: Well Foundation Property Line r SEEPAGE 15I75 ❑ Depth Size Number i-- SUMPS ❑,. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 jLocal Health District. Homeowner 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." i The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY I Application Accepted by Date Area Pit or Grout Inspection Date Final Inspection by Date - � + I Additional Comments: ! ] / 71 u S �5 8 ?, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑,Manteca 823-7104 . ❑ Tracy As 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 C RECEIVED 8Y DATE PERMIT'NO. # I INFO SH + EH 13-24 TREY.l/n 51 � f EH 14-26 s k