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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 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. 7 D�r.. Job Address spa 22_1 City - Lot Size PM Owner's Name� ��'�a(16& — Address Phone �� t ContractorY 4 r___. —Address License Noir 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 CONSTRUCTION SPECIFICATIONS ` L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth I 1 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 INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) 1 Installation will serve: Residence_____ Commercial— Other j 'hn Number of living units: _U_ Number o bedrooms Character of soil to a depth of 3 feet: — ��'�- Water table depth r SEPTIC TANK o- Type/Mfg 0&►...r - Capacity_-r a.v vv No. Compartments PKG. TREATMENT PLT. ❑ Method ofDiissp(I�sal Distance to nearest: Well 3 Foundation Property Line/000 LEACHING LINE 4Pi' No. & Length of line % +}�Total length/size FILTER BED ❑ Distance to nearest: Well�p r Foundation Property Line_ r} f+ SEEPAGE PITS P'f Depth A, _Size Number SUMPS Ll Distance to nearest: Well Foundation PC) r Property Line ;?o DISPOSAL PONDS ❑ I hereby certify that I have prepared this appllcation 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 Ditrict. 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 must call f r al squired inspections. Complete drawing on reverse side. Signed X TitleDam-, Date: FOR DE ARTMENT USE ONLY Application Accepted by Date r� Area 01 r Grout Inspection by ate Final Inspection h,-7,- �Date/L�Q_ 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 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ��/) +.EH 13-24(FEV.l/H 5) 70,,G 1/a f o j qi 2- ! 37-,2r EH 14-28 v