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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE., STOCKTON, CAS y ' Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. �f i Job Address ` / f 2�t✓� City 1'V� Lot Size PM 79 I 's Name �Owner1 ress e 39-3/ Q , . [� �I Contractor 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 T CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing } ❑ Domestic/Private Gravel Pack ❑'Tracy Type of Casing Specifications f'1 Public i7 Other ❑ Delta Depth of Grout Seal Type of Grout 11 Irrigation _..Approx. De In ' I I Eastern � � Surface Seal Installed by Repair Work Done ❑ Type of Pump*_ H State Work Done Well Destruction ❑ Well Diameter hSealing,Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATI N ( 1 REPAIRIA DITION € I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence �? .Commercial Othei Number`of living units: Number of bedroom �- Character of soil to a depth of 3 feet:•x _ Water table depth SEPTIC TANK fad Type/Mfg._(� ., Capacity �� No. Compartments PKG. TREATMENT PLT. ❑ / Method of DiVosal s Distance to nearest: Well - Foundation Property.Line - k LEACHING LINE No. & Length"of lines Total length/size s FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth }Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ { herebyertify that l have prepared this application and�that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules anctTgulations 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 the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applican.t.Nst call for all required ins actions. Co tete drawing on reverse side. a�y Signed XCt .� 1.drYLrJ Lllll~Title: ©a,17zg Date: R DEPARTMENT USE ONLY r {. Application Accepted by Date �� rea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 A INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY f DATE PERMI7'NO, *,EH f3-241REV.1/a51 ' EH 14-26 Ic0