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t} 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 I (Complete in Triplicate) t 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. Jab Address S Cr 4ad City Lot Size PM Owner's Name Address R 1PQ 4 A5 I Phone Contractor's Name .�- + License No. Phone T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by W Repair Work Done ❑^ Type of Pump H.P. State Work bone Well Destruction El Well Diameter Seating Material ftop 50'} Depth Filler Material {Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: .Residence Commercial_ Other Number of living units: Number of bedrooms ` ,_ yF 0 Character of soil to a depth of 3 feet: Water table depth V� i SEPTIC TANK ❑ :Type/Mfg' 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal I Distance to nearest: UVeI! Foundation Property Line t LEACHING LINE q� No. & Length of,lines 146 Tolallength/size FILTER BED l ^i / 11 �^, ❑ Distance to nearest: Well i��}= Foundation _ Property Line SEEPAGE PITS ' ❑ Depth 7. Size Number i SUMPS w,Distance to nearest: Well 1(10 Foundation—22� Property Line �� I DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, rules and regulations of the San Joaquin Local Health District. state laws, and 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`ll for all repyjied inspections. Complete drawing on reverse sides-• - w Signed 1J� Title:, f Date: FOR DEPARTMENT USE ONLY Application Accepted by , •x aa-L— Date Area 6 Pit or Grout Inspection by' Date { Final Inspection by Date -�f ✓ Additional Comments: .� ❑ Stk 466-6781 ❑ Lodi 369-3621 CI 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 I r FEE gMOUNT DUE AMOUNT REMITTED INFO CK RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV,101e31 � �(� EH 1426