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APPLICATION FOR PERMIT a S� 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA. Telephone (209) 466-6781 s " PERMIT EXPIRES TYEAR 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 well1pump and the Rules and Regulations of the San Joaquin Local Health District. ij Job Address f4 Lot Size?'� G ' PM i 1 _. Address Phone 2c/r/V,7 €I Owner's Name Contractor V Cr �T Address / s1 t J �sC/� r� License No.��S 7�� Phone 3 TYPE OF"WELL/PUMP: -NEW WELL ❑ WELL REPLACEMENT ❑ -DESTRUCTION ❑ k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD: PROP. LINE jFOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS fFI INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑Open Bottom- _ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ,� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f 1-1 Public F1°Other Cl Delta Depth of Grout Seal Type of Grout - s #€ I I Irrigations 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 501 f Depth Filler Material IBelow 501 II, TYPE OF SEPTIC WORK: NEW INSTALLATION lir! REPAIR/ADDITION IJ DESTRUCTION I 1 INo septic system permitted if public sewer is r r available within 200 feet.) Installation will serve:" Residence Commercial_ Othe T Y m Number of living units: _/_ Number.o bedrooms Character of soil to a depth of 3 feet: Water table depth 2 ',y SEPTIC TANK �' Type/Mfg Capacity G No. Compartments i PKG..TREATMENT PLT. ❑ .` Method of Disposal t t Distance to nearest: Well Srd t � Foundation A) Property Line � f F LEACHING LINE 129'7No. & Length of lines� � �� Total length/size Qf FILTER BED I- Distance to nearest: Well Foundation 02-0 Property Line SEEPAGE PITS I'f`bepth C)a S t Size 3 4 __ Number `' SUMPS Ll m Distance to nearest: Well f 00 Foundation 7 Property Lin � e s _.-_ {;{ DISPOSAL PONDS 0!N 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, i rules and regulations of the San Joaquin Local Health District. E . i i� Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work"for_wVhich this permit is issued, I.shall not E1 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 law's of California." '+ The applicant must call fo II re red inspections. Complete drawing on reverse side. Signed X Title:- N Date: 1 FOR DEPARTMENT USE ONLY A plication Accepted by Date i or Grout Inspection by Date. o v Final Inspection by Date € Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t k Applicant - Return all copies to: Envifonmental--Health"Permit/Services 1601-E-Hazelton Ave:-P:O:-Box-2009;"Stk:,-CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT NO. + EH 13-24 01W.1 851 EH 1428 - .. i