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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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 i s 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 - e- City Lot Size PM v� i Owner's Name � � Ci.�4 P,r ,�X Address AY Phone 4 4 Contractor's Name ,��` d r7 L E AeLicense No. ` �,5 I Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM APAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLM --s--PROP. LINE FOUNDATION j AGRICULTURE WELL OTHER,WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r 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 r Repair Work Done ❑ Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material {top 501 0 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) i Installation will serve: Residence_Aff"Commercial_ Other f Number of living units: _,L____ Number of bedrooms Character of soil to a depth of 3 feet: f 6Z Z)r/ 4 o.A A'1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1� _ Method of Disposal rd � �. Distance to nearest: Well w r Foundation Property Line LEACHING LINE ❑ No. & Length of lines X az47 F Total le'n'gth/-size .2,0 S� FILTER BED Distance to nearest: Well Foundation�— Property Line fO SEEPAGE PITS ❑ Depth I Size --.. E Number i SUMPS ❑ Distance to nearest: Well FoundationvP-roperty Line s 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. } A Home owner or licensed agent's signature certifie'a the following:"'I certify that in the pefformance 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 call f all re Prod inspections.-Cpmplete drawing on reverse side. j Signed Title: 8 Date: - P /FOR DEPARTMENT USE ONLY r Application Accepted by pate Pit or Grout Inspection by tv Date�°'� Final Inspection by ' l Oate_ .e Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3521 , gnteca._823-7104 ~"❑,Trady-;835-6385 _a Applicant--Return all>copies to:-Environmentai ea 'Pe'tm`if/Servioes 1601=E.'Haieltdn A e:`p:0. 136x-AW, Stk.; CA.95201 FEE CK INFO AMOUNT DUE -AMOUNT-REMITTED T CASH, RECEIVED SY w f DATE - PERMIT_`NO. _ �+ EH 1324(REV.10!83! Ll i o /' 7", EH 1436