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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 I 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address + ? � rs City r Lot Size.- PM -Owner's Name 4 ¢ Address rX.Glr_c Phone Contract � Address 6&% �Vt 7 49:r "` License Nolla r2G Phone3L� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ T 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 ,O'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 F Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION UK REPAIR/.ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .. F available within 200 feet.) Installation will serve: Residence/ Commercial -Other Number of living units:_L_ Number of bedrooms A Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i/ Type/Mfg Ct2VC, Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of DiTosal Distance to nearest: Well Foundation _J40 Property Line 5-- LEACHING LEACHING LINE U No. & Length of lines Total length/size len,26 X FILTER BED ❑ Distance to nearest: Well 1012 Foundation /,Q Property Line SEEPAGE PITS 91"_"Depth _Size Number `7 SUMPS ❑ Distance to nearest: Well -(��.__ Foundation Property Line DISPOSAL PONDS ❑ 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.,' . . --- The -The applicant mu t call for all required inspections. Complete_drawing on reverse side. Signed ] ALL Title: •_�. Date: t!E �^ fFOR DEP RTMENT USE rONLY r Application Accepted by 7z:u- Date "Area P iitJ///-1�r Grout Inspection by Date "Final Inspection bv�� ate Additional Comments: - ❑ Stk 466-6781 El Lodi 369-3621, ❑ Manteca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT-REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.f/a5) gs-0v EH 14-26 1_+'