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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 _[ % S c /s- 'A / kl d /7 k Cit f 3~ifl y . Lot Size loo Y SHAD PM Owner's Name 46 /`�,G�' }��/tC' s' Address ��%� /If= Phone 7 Contractor's Name 10,e TX 1Jr1.e / -Vlrws License No. 2.J Y - 3 5�� Phone '1916101 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation _ Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel -Pack 0 -Tracy-- Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout ❑ Irrigation f ---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') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: R�es�dence Commercial _ Other _ - Number of living units: Number of bedrooms 3 '� Character of soil to a depth -of 3 feet: -� Water table depth G Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. O Method of Disposal "Distance to nearest: Well Foundation Property Line LEACHING LINENo. &Len th of lines 9 % �Q Total length/size G X 2 - FILTER BED ❑ Distance,to nearest: Well Foundation Cb Property Line 14 SEEPAGE PITS _ _ ..P-<DepthZX`* Number ` SUMPS ❑ Distance to nearest: Well M44 r _ Foundation 10A, I Property Line _ f DISPOSAL PONDS El neanuy cxrury mal 1 nave 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: 1 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 t call for all requirect`ns� do s. Completa drawing -on reverse sid$ y,� Signed c Title: I_� I--�i / _ Date: FOR DEPARTMENT USE ONLY gg Application Accepted by Date~ L" Area t� f (9 1, Grout Inspection by 7�y ate _ Final Inspection by t '/Dated° Additional Comments: ❑ Stk 4666781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all opi s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 1324 (REV, 161631 EH 1426 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT' N0. `.