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l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t\� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heioby 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 Oz y �40 /r City Lot Size PM Owner's Name Address _ Phone —71 Contractor��fl� Atldress Y �' �/ �� __license No.�� Phone TYPE OF WELL/PU P: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION D SYSTEM REPAIR=' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE8 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 ❑ Gravel Pack ❑Tracy Type of Casing --- _ Specifications (1 Public ❑ Other 11 Delta Dd3 th of Grout Seal"""'---f Type of Grout I I Irrigation . __App(ox, Depth I I EasternSurface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P., -State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material I8elow,50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l DESTRUCTIONI'I (No septic system permitted if public sewer is available within 200 feet.) U Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms 3 �r, / Character of soil to a depth of 3 feet: &a ; i t Water table depth / I n SEPTIC TANK ElType/Mfg Capacity 1�By No. Compartments V, i' PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well t Foundation X_ Property Line LEACHING LINE ❑ No. & Length of lines Notal length/size i un FILTER BED ❑ Distance to nearest: We 'un WL-11 : Fodation Property Line� SEEPAGE PITS 11 Depth Size :_" }' Number, SUMPS L) Distance to nearest: Well�s Foundations Property Line DISPOSAL PONDS ❑ r f hereby certify that I have prepared this application and that the work wolf be done in accordance with San 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 performance of the w6rk-for which this permit is issued, 1 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 forwhich this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." f The applicant must call for all required-inspections. Complete drawing on rev.)" side. . Signed X wI 11 KY. .Y Title: Date: If 4 u OR li,).POARTMNT U E ONLY- Application Accepted byF` �= Date Area_ 2 I Pit or Grout Inspection by Dat Final Inspection by Date/ S Additional Comments: '- F ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-67.85 Applicant- Return all copies to: Environmental Heahh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 1324 IREV.t/n 5) - 1 EH 14-2e