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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. Job Address �/J � `/�- City F-��/ s'u� Lot Size PM Owner's Name Address Phone 4. } Contractor's Name ka License No. 30S 721 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing r I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---.4pprox. Depth ❑ Eastern-•--• Surface Seal Installed-by Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO. DESTRUCTION (No septic system permitted if public sew r is a ailable within 209 feet:) � Installation will serve: Residence Commercial_ Other Number of living units: � Number of bedrooms- 3 Character of'soil to a depth of 3 feet:"..S'A;�1t�... Loin•:' Water table depth SEPTIC TANK' 1!�—Type/Mfg jzt3�t � Capacity 1.15 No: Compartments �+ t PKG. TREATMENT PLT. ❑ + _ FF. Method of Disposal ` Distance to nearest: Well J Foundation 10 Property Line 0 ' LEACHING LINE B' No. & Length of lines CFO �"• f} j f Total length/size—"Opo f f FILTER BED k' LJ Distance fto nearest: Well �f -Foundation `40 r Property Line 10 SEEPAGE PITS CY Depth —S c r Size ! �� Number '{ IV SUMPS Ca- Distance'to nearest: Well Foundation-0 / Property Line 10 r ' 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 whichsthis permit is issued, I shall not employ any person in such manner as to become subject to wgrkman'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 aIi fo all required inspections. Complete drawing on,reverse side. t b T1tle•`� GC1 A)e- fDate- Signed X FOR DEPARTMENT-,USE ONLY Application Accepted by }-- f'! "': I j i Date Area Pit or Grout Inspection by dateb •Final.Inspection.by # Data I d o Additional Comments: ❑ Stk 466-6781- — ❑ Lodi-:369 3621 ---^ ❑-Manteca--623=7104- �----❑:Tracy.-835-6385 •^-�-^ ��r Applicant- Return all copies toI Environmental Health-Parniit/Services 1601 E. Hazelton Ave., P:O:Box 2009,,Stk:, CA-95201 I .. Ile t a'w.f FEE i X INFO AMOUNT DUl 1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•'NO. IC3 r + EH13-28(REV.10!931 / —r 310 EH 1428