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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEr_TON AVE.; STOCKTON, CA 3 Telephone (209) 466-6781,. i 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 Local Health District. ' ^� .Sy\' � it ..,F ♦� - i Job Address `� ! ' City / Lot Size PIM Owner's Name l.Q �1a1 Address 7U Phone ' r ��9 330 Address / � C�C DlQ�JUs License No. Phone Contractor \ ` 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 O Manteca' .t Dia.`of Well Excavation Dia.-of Well Casing ❑ Domestic/Private ❑ Gravel Pack. _ ❑ Tracy -' Type of'Casing Specifications ❑ Public ❑ Other ❑ Delta i 'Depth of Grout Seal Type of Grout %_1 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t' Repair Work Done ❑ Type of Pump H.P. i State Work Done Well Destruction C1 Well Diameter } Sealing Material stop 501 Depth Filler Mateiial-(BBldw' .50'I TYPE OF SEPTIC WORK: NEW INSTALLATION 'REPAIR/ADDITION ET DESTRUCTION ❑ {No septic system permitted if public sewer is I available within 200`feet.l Installation will serve: Residence L Commercial_ Other ' Number of living units: —I— Number of bedroo s -__.,-_— ' V Character of soil to a depth of 3 feet: J •� � Water table depth r SEPTIC TANK { V Type/Mfg Capacity s No. Compartments f PKG. TREATMENT PLT. ❑ _ r w;. Method of Disposal Distance to nearest: Well r r Foundation Property Line_-.�i� 1- `! LEACHING LINE M R No. & Length of lines t J- —`F8�— cT,_tal_length/size j FILTER BED # ❑ Distance to nearest: Wei.] U S Foundation 301 Property Line 1 SEEPAGE PITS # E1Depth f Size ( 1 Number - SUMPS 1 11k""Distance to nearest: Well_ � Foundation S I Property Line 35 F DISPOSAL PONDS ` ❑ k 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.fhe work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." _ t` The applicant must call for 2P requ"ed inspections. Complete drawing on reverse side. �r Date: 2�� Signed Title: - i I FOR DEPARTMENT USE ONLY 1 F "� Application Accepted by Date Area V ..._....... ..... ,- - Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6181 0FLodi 369-3621 ❑ Manteca 823-7104 Ift Tracy 83AM Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO CASH �/ 7 + EH 13-241REV.i/ar) EH 14.26