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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED f (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. S3O/f(,yo, Job Address � City Lot Size -C- PM'7 Owner's Name — 4) Address +� Phone /" ''�1` Contractor Address_ License N 7,2L--PhoneL?r 83JU i 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private l ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l FI Public n Other Cl Delta Depth of Grout Seal Type of Grout i_I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by I I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INS7Commercial TION REPAIR/ADDITION 1.1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Re 'dente 7 — Other f -Number of living units: - Number rooms._._. _.— �Q J Character of soil to a depth of 3 feet- Water table depth SEPTIC TANK Type/Mfg Capacity &W No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WellFoundation Property Line LEACHING LINE to. & Length of lines d Total length/size ZoZ---No. �� l FILTER BED ❑ Distance to nearest: Well Foundation ]�_._ ._. Property Line J SEEPAGE PITS I{I/Depth Size Number SUMPS Ll Distance to nearest: Well r Ftoundation_-._ 7-± Property Line toy 1 i DISPOSAL PONDS ❑ l R 1 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 District. Ir -�f a.3 r � ' 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 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." f = r The appli t m t call f r all require ins ctions. Complete drawing on:reverse-side.-" "� i Signed X Title: AA Date: [O �! � �' i 1 FOR DEPARTMENT USE ONLY j Application Accepted by Date ` � (� Area �- s 6d.ditional rGrout Ins ��,�9pection by ate� Final Inspection by DateComments: ❑,Stk-466-6781-0 Lodi-369-3621-- ❑•Manteca-823-7104 ❑-Ttacy^-835=6 5" '""`""'"""' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT:NO. ♦.EH 1 -24(REV.IiH5) 2F EH 144-26