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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 (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 I Local Health District. rd^ t-� Job Address OL - LlCLSSG G City Lot Size PM Owner's Name + ho�x.s r� ` r11 Address A tp-(T � , p (/ s Phone a � /S �7 Contractor 59 t Address License No. Phone 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 PITSISUMPS I INTENDED USE TXPE-OF—WELL,,.,_,.PR09LEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r1'Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation T J _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 — Depth Filler Material {Below 501 _ V TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: —I— Number of bedrooms Character of soil to a depth of 3 feet: `-Water table depth V J SEPTIC TANK ❑ Type/MfgCapacity__ No. Compartments f y � a PKG. TREATMENT PLT. ❑ f f ' Method of Disposal I -* Distance to nearest: Well T� Foundation w Property Line'i— LEACHING LINE No, 11 Length of lines U Total length/size FILTER BED ❑ Distance to pearest: Well Foundation Property Line - SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 i rules and regulations of the San Joaquin Local Health Diltrict. " Home owner or licensed agent's signature certifies the following: "I certify that in the performance f 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." +r--.� r - r The applicantuipip calf for all r uired inspections. Complete drawing on reverse side. Signed X— _ Title: ,PDate: FOR DEPARTMENT USE ONLY Application Accepted by pate Area Pit or Grout Inspection by Date Final.Inspection by x � Date Additional Comments: D � C1Stk 466-6781 El Lodi 369-362f ❑ 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 AMOUNT REMITTED EH 1321(REV. /x 51 INFO CA 9 K H RECEIVED BY DATE PEll MIO EH 14-26 + f �-2--S- t_