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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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i y�G Job Address sG City Lot Size PM Q y - G Address Phone Owner's Name' '^77 //GG I Contractor ! Address it 7E 01 License No37 �� PhoneI o"5/b ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA_T_ION ❑ .4 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 ❑ Industrial ❑ Open Bottom Li Manteca Dia. of Well Excavation I Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _ Approx. Depth t'1 Eastern Surface Seal Installed by ' H.P. State Work Done Repair Work Do �{nee0 Type of Pump r Well Destruction ❑ .,Well Diameter Sealing Material (top 50'1 *" Depth Filler Material (Low 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ) DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) a installation will serve: Residence— CommercialOther�r� __d mS�— i Number of living units: Number of bedrooms �� f Character of soil to a depth of 3 feet: Rix s Water table depth SEPTIC TANK [ Type/Mfg w r _ Capacity �� No. Compartm ns� Z PKG: TREATMENT PLT. El ;r Method of Disposal Distance to nearest: Well 5_ Foundation-_J ) Property Line — --� <59 /1< 5� Total len thlsize � LEACHING LINE � No. & Length of lines ` g f ,FILTER BED ❑ Distance to nearest: Well - 60-- - Foundation�10/ Property Line -5 5 y� , SEEPAGE PITS ) Depth t ✓r/ Size 3 _ Number i� SUMPS ❑ 'Distance to nearest: Well lk / Foundation - 10 ! Property'Line DISPOSAL PONDS ❑ _ I hereby certify that I have prepared this application and fhat the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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 I empioy any person in such manner a`s 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 dhis,permit is issued, I shall employ persons subject to workman's compensa ' tion laws of California." i The applicant mug call for all required 'nspections. Complete drawing on reverse side. ._ Signed X Title: Date: r� - FOR DEPARTMENT USE ONLY g `/11 Application Accepted by Date 3 c Area r " J Pi or Grout Inspection by Daie.S S ;��1Final Inspection by Date I Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 C3 Tracy 835-6365 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 CASH RECEIVED BY DATE PERMIT NO. INFO +.EH 13-24 IREV.i/n 51 --�� ' �Rq 9{� EH 14-26