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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is fieteby 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. Cc.�C.A-4-) OG � l �s'�a�sr 9(1�e+-C.. Cir � Lot size J PM Job Address l' Owner's Name Address NCO( 01 ` T $� f7 Phone 30-I TLAS ContractAw " W Address P.0, _10 License No._J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 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 I'1 Public n Other ❑ Delta Depth of Grout Seal l ` Type of Grout C3 I 1 Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by - d Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I.1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) (� Installation will serve: Residence Y Commercial_ Other y C Number of living units: I Number o edrooms too Character of soil to a depth of 3 feet: # Water cable depth SEPTIC TANK i�Type/Mfg I Capacity t00Q No. Compartments PKG. TREATMENT PLT. ❑ f r Method of Disposal 1 Distance to nearest: Well 0 Foundation— Pl^operty Line;& LEACHING LINE LH" No. & Length of lines Total length/size 1400 )( FILTER BED ❑ Distance to nearest: Well O f' Foundation Property Line 51 1 SEEPAGE PITS l 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 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."Contractors 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." Theapplicant must call for all required inspections. Complete drawing on reverse side. Q Signed X Title: v ". Date: FOR-DEPARTMENT USE ONLY Application Accepted by r Date ' Area Pit or Grout Inspection A bye Date Final^Inspection by Date ts: Additional Commen1, a f Ax� zAL �- ❑ Stk 466-8781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 'y`ylu�r ��„41"'ew- jou 2--:"f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /d 011: � �y IFEE NFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT'NO. a EH53-24{REV.i/x sl Ila Y� F7 7'1JS 73, /� 1V EH 14-29