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a 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 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 Job Address 14 77k S �� City Lot Size �Cr� 3��. PM Owner's Name �Q Address /� Y "'" ��~ Phone e��/�` l Contractor ©kw) Address-1 0.04rKle—'05-1 License No. � Phone / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. 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 1`1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump' H.P. _ . State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1'` Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION I I DESTRUCTION I i Mo septic system permitted it public sewer is available within 200 feet./ Installation will serve: Residence_X_ Commercial_Other Number of.living units: _L Number f edroo Character of soil to a depth of 3 feet: Water table depth ~ SEPTIC TANK t Q Type/Mfg` PC Capacity A74019 No. Compartments PKG. TREATMENT PLT: ❑ Method of Disp I osal �/�n r Distance-to nearest: Well Foundation Property Line = LEACHING LINE No. &,Length of lines - T tal length/size 14,749 FILTER BED ❑ Distancl to nearest: Well Foundation Property Line - 6 SEEPAGE PITS i I Depth Size lyu ber r O SUMPS rY" Distance to nearest: Well Foundation Property Line ZQ DISPOSAL PONDS Ll lg '� I hereby certify that I have prepared this application and that the work will be done i ccordance 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 not11 employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,.l shall employ persons subject to workman's compensa- tion laws of California." The applicant rrtuyt cV for all required inspec ns. Complete drawing on re rse si Signed X Title: /" l Date: 4?4 7 FOR DEPARTMENT USE ONLY 7 Application Accepted by Date �^ � � ! Area 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 2009r'Stk„ CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.I/H 5170 EH 1428 f J