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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R 1601 E.-HAZEL I ON 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 �._� iaD C' C� � Lot Size 6 r'7 )( 16 r ,PM Owner's Nan Com- 4 Address S 7 7 /J9,&e' C 12© Phone Contractor '�l� 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 PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private,,,w,,,,,E7 Gravel Pack._. ❑ Tracy Type of Casing Specifications ❑ PublicElOther ❑ Delta Depth of Grout Seal Type of Grout E ❑ Irrigation —J�pprox. Depth El Eastern Surface Seal Installed by r Repair Work Do e ❑ Type of PUMP I H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 l I Depth # r - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ElGREPA /AD!WION DESTRUCTION 3 ANdo septic system permi ed if public sewer is ilable within 200 fee .1. Installation will serve: Resident` Commercial_ Other AL ✓ Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ ype/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LDNo. & Length of lines. - -- .r Total length/size _ a- ;•e= ta FILTER BED ❑ Distance to nearest: Well :�foundation._il� �Propertq Line t SEEPAGE PITS ❑ Depth Size f t Number SUMPS ❑* Distance to nearest: —Well-- ow +Foundation fE..- =Property Line DISPOSAL PONDS f ❑ 1 hereby certify that f 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. I 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,.1 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 rtitust gall forw4a;: i S. ete drawing on reverse side. 41 � Signed g Title: i I { FOR DEPARTMENT USE ONLY Application Accepted Date r2 Area Pit or Grout Inspection by Date Final Inspection Data? 12-rr{{b Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 Applicant- Return all 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 PERM11'NO. INFO + EH 13-24 IREV.',,5) {- EH 1426