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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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 Local Health District. Job Address RIP City �o Lot Size 3 PM Owner's Name Address Zr 'er '07R Phone Contractor 04 ez, _ G�/Z 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 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 11 Public ❑ Other ❑ Delta ,r-Depth of Grout Seal Type of Grout .r I I Irrigation _f*proox. Depth l 1 Eastern Surface Seal Installed-.by_!T _-. - Repair Work Done ❑ Type of Pump H.P. x k State Wgrk Done_ CIO Well Destruction ❑ Well Diameter Sealing Material (top 501 T Depth Filler Material (Below'501 — TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION h l INo septic system permitted if public sewer is available within 200'feet.) Installation will serve: Residence L Commercial_ Other Number of living units: _)— Number of bedrooms. 5 Character of soil to a depth of 3 feet: e4 Water table depth SEPTIC TANK ❑ Type/Mfg = 2— 726!9 A -_ Gapacity• No. Compartments PKG. TREATMENT PLT. [D ,f,� Method of Disposal Distance to nearest: Well�crr Foundation mot _ Property Line LEACHING LINE No. & Length of lines -7— r�/�Total length/size FILTER BED ❑ Distance to nearest: Well jr�Foundation�!--..--.'-.- Property tine_6�3___1__ SEEPAGE PITS i I Depth fT -1—_r Size AIX r .-dam+ _ SUMPS { Distance to nearest: Well Foundation�1�� %roperty Line a � 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 workm. gn's compensation taws of California."Contractor's hiring or sub-contracting signature certifies the fotlowing: "I certify that in the performance of the work for which this permit is issued, I shall employ p6tsons subject to workman's compensa- tion laws of California." Thecapplicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: I, f FO€i DEPARTMENT USE ONLY ! Application Accepted by Date Area_ Z[ (11 • ^r Pit or Grout Inspection by Pate Final Inspection by ate C a'Ij Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _4 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ©ATE PERMIVNO. • c 7 -7d C �j t EH 13-241R ix51 f�� 0 ?1 ^�5p3 £H t4-26