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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ± Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ '1 + (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 .SA lCi /� tY CZ '�Y' Lot Size��`� PM Owner's Name iL /0* p A/ Address _ 3 , Phone �� t Contractor Address 7 mc) License No. :Phone TYPE OF WELL/PUMP: NKV WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AL FLD. PROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom eco Dia. of Well Excavation Dia. of Well Casing 1-1 Domestic/Private Ll Gravel Pay 0 Tracy Type of Casing Specifications ❑ Public r El Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal installed by Repair Wo brie ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is { ra { ti ;i available within 200 feet.) ! 'Installation will serve: Residence_ Commercial Other ' + Number of living units:-/__ Numb r of bedrooms_ c . Character of-soil w a-depth of 3 feet: -( .� 4 �� Water table depth l SEPTIC TANK ❑ Type/Mfg _ opacity No. Compartments �. PKG. TREATMENT PLT. F7 `- yr i Method of Disposal ; '^ham t Distance to nearest: Well�� Foundation_ i Property Line LEACHING 'LINE No. & Lerigtof lines h Tal length/size FILTER BED ❑ Distance to nearest: Well vge� Foundatiori _ Property Line SEEPAGE PITS Depth � Size- Number_ SUMPS ❑ Distance to nearest: Well y0e:C(L Foundation 0 ' _ Property Line1L� DISPOSAL PONDS ❑ I I hereby certify that ! have prepared this application and that the work will be done in accordance with'San Joaquin county ordinances, state laws, rules and regulations of the San Joaquin Local Health District: aws, and9 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, L 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,!shall employ persons subject to workman's compensa- tion laws of California." The applican st call for all requ' ins ctions. Complete drawingonf'f6ie-ise side. + Signedy Title: bate: X FOR DEPARTMENT USE ONLY Application Accepted Accepted by Date Area '. Pit or Grout Inspection by Date- Final Inspection byw_ 4Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE 1 AMOUNT REMITTED INFO �p CA { SH RECEIVED BY DATE PERMIT'NO. EH 14.28 VV + EH 13-24 fREV.t/851 ''/1 k