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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 (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. 4 Job Address /!J City Lot Size PM t Owner's Name k44'A_J All A-/0 Address phone rpContractor A0 Address License No Phone 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 ❑ Tracy Type of Casing Specifications M Public ❑ Other n Delta Depth of Grout Seal Type of Grout_— I I Irrigation ____.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 -- -�, TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.1 `Eristatl$tion will serve: Residence f�ommercial Other Number of living units: F�•� _ Number of bedrooms Character of soil to a depth of 3 feet:, CXZI4' -- AA Water table depth f!"" t SEPTIC TANK ype/Mfg �.� �� _ Capacity�� Q No. Compartments PKG, TREATMENT PLT. ❑ ; Method of Disposal Distance to nearest: Well Foundation 1 Property Line yn LEACHING LINE lie �s No. & Length of lines `~r � __ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Ne-1f Property Line P-45- SEEPAGE PITS i I Depth Size Number t SUMPS Distance to nearest: Well Foundation , Property Line�T DISPOSAL PONDS ❑ r ` 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 t rules and regulations of the San Joaquin Local Health District. r 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 `166ifies 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#require inspec"ons. Complete drawing on re side. y Signed X Title: Date: 1y ' 2=PARTgNT USE ONLY (� t ` Application Accepted by Date 0 Ar ow?% ` +1 Pit or Grout Inspection by Date Final Inspection by Date` 6 Additidnal Comments: ❑ Stk 466-6781 ❑ Lodi 3M-3621 ❑ Manteca' 823-7104 ❑ Tracy 835-6385 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 CK 4 RECEIVED BY DATE PERMIT•NO. INFO GASH _• ♦ EH 13-24 UIEV.lix51 { l ` �J�-�yU �Q og� . Y EH 1128 1 {