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APPLICATION FOR PERMIT SAN JOAGUIN LOCAL HEALTH DISTRICT 1601 E. HAZLL T ON AVE., STOCKTON, CA \ Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he(eby 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 I l:,2 e).4 161tY ' r JJ Owner's Natfte�• / • �' / ! Lot Size— Address 6F,41 �%✓ �� ( -7 PhA Contraclor%� Phone AddresstA7 l ,� fes?,�d�E e Noir/ j 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 PIT$/SUMPS INTENDED USE TYPE OF WELL _ PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth _ I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Material ltop 50'1 Depth Filler Material (Below 50') TYPE OF'SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if sewer is ` public available.within 200 feet.) Installation will serve: Residence XCommercial Other ____ Number of living units: __/_ Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK Type/Mfg Cl Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal . Distance to nearest: Well Foundation Property Line 175 LEACHING LINE No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation /©J'� Property Line SEEPAGE PITS Depth "'Z5 Size Number SUMPS L1 Distance to nearest: Wel� �j-- Foundation �S 4Property Line DISPOSAL PONDS 0 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 workman's compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the pe mance of the work for which this permit is issued, I shall employ tion laws of California." p Y persons subject to workman's compensa- The appli nt ust c I or all requ'r i ctio . Co plate drawing onars side. p Signed Title: Date: 11 FOR DEPARTMENT USE ONLY Application Accepted by Date — T 0 Area or Grout Inspection byc-'r/� Date 1---/ x Final Inspection by Data% 7 A itional Comments; Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 d Iicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 EH 13-24 (REV. Si EH t4 -2e FEE AMOUNT DUE AMOUNT RPMITTEO INFO r-� CK RECEIVED 6Y DATE PERM17,NO.