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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.' STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a - (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. PM lO AXVr d CALe-A� Job Address Z/l2/Y1 Ci)ty� ] Lot Size Owner's Name Add . 9?A �l/� d �AA Phone 2 3 3`Q Q w t � Contracto 2 �cP Phone . _ Address 1`�� c7J47r �(� License No. ' TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl r ( /► + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 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 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material (Below 50')-' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permittia&f public sewer is r available within 200 feet.); Installation,will serve: Residence Commercial____ Other U Number of living units: � Number of rooms A + k f i Character of soil to a depth of 3 feet: Vii'--A Water table depth ,Q k�. SEPTIC TANK O Type/Mfg— — T Capacity No. Compartments C� t PKG. TREATMENT PLT. ❑ � ;1 i Method of Disposal �-�--- - - Distance-to-nearest:__Well -^—Foundation Property Line ; LEACHING LINE ®-`No. & Length of lines :—Total length/size- 114X FILTER;D + ❑ Distance to nearest: Well es Foundation //9 j Property Line:f_ SEEPAGE PITS LSI Depth cis Size. Number 79 i ` SUMPS- ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ II 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."Contractors 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 for all required inspections. Complete drawing on_reverse side, F Signed i C Title: V Date: t +! FOR DEPARTMENT USE ONLY FF •:.f �s Application Accepted by r Date 4 Area O r } . Pit or Grout Inspection by Date c Final Inspection by s Date ' " Additional Colriments: }'� 14 ❑ Stk 466-6781 ❑ Lodi 369-3621"' ❑ Manteca 823-7104 ❑ Tracy 835-6385 17 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 A FEEi INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. tY4 EH13-241REV. /e 57 EH 14-28