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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 3'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 Rules and Regulations of the San Joaquin Local Health District. Job Address � �� 5 CityLot Size PM Owner's Name !t rl E ao / 1 "Address r uc Phone Contractor Address �G / License N 7 s Sf Phone r �� 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other f 1 Delta Depth of Grout Seal Type of Grout-- I rout__I I Irrigation ..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 Itop 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_kf Commercial_ Other Number of living units: __-/_._.- Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity/Aet-_o No. Compartments PKG. TREATMENT PLT. ❑ T f-j Method of Disposal Distance to nearest: Well •S{ Foundation 45 Property Line LEACHING LINE No. & Length of lineszZC6E(9 1` Total length/size eq FILTER BED LJ Distance to nearest: Well err, Foundation ZZ I T Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ul Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Local Health District. 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." The applicant must call for,dl requiped inspections. Complete drawing on reverse side. Signed X Title: ��-:.�-eitr/ _ _ _ Date: " i F DEPA MENT USE ONLY Application Accepted byeo�el�46Date Q Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: .. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED MASH RECEIVED BY DATE PERMIT NO. + EH 13-24 IREV.iin sl 77� EH 14-26 / J 1