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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1 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 Na. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health' District, j Job Address - ` City Lot Size L' PM -4- A (L Owner's Name Address -� Phone © r Contractor -1 1.1 1ff_C.yn"`W= Address 7 Ce T f - — 11,F— License Note Phone -5(-C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, . SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial ❑ Domestic/ Private FI Public I I Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Gravel Pack Other —..Approx. Depth Type of Pump Well Diameter Depth ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing F1 Delta Depth of Grout Seal 1 I Eastern Surface Seal Installed.by H. P. �` State Work Done _ Sealing Material (top1. .50:)`E Filler Material (Bel TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR /ADDITION' 1 DESTRUCTION 1 1 INo septic system permitte I I available within 200 feet.) Installation will serve: Residence +Commercial Other ' " Number of living units: Number of bedrooms �Characier•of-soil•to"a-depttt of 3feeet: / ��—Water table depth_ SEPTIC TANK a_11" ❑ Type/Mfg Capacity / �Ll No. Compartments PKG. TREATMENT PLT. D w �r f I Method of Dispo.Yal . t Tye- fDistance to7nearest: well U Foundation s Property,line _'�t� 77 , f LEACHING LINE J ❑' No.&^Length of lines `� a," Total length/size t FILTER BED ❑ Distance to nearest: Well/N_01- Foundation / }� Property Line SEEPAGE PITS I I DepthX_L-2A " Size ��-- Number M�P ❑ Distance to nearesl!� -Welll • r -Foundation Property Line r IS�1 POSAL PONDS ❑ Dia. of Well Casing Specifications Type of Grout public Sewer is I 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 DiMrict. i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wort: 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." f The applicant If- r al qu m pections. Comple drawing on reverse side. f _-... _-. Signed X � Title: �._- Date: FOR DEPARTMENT USE ONLY Application Accepted byDate �/�L//� rArea Pit or Grout Inspection by Date _ Final Inspection by <G) ,d�./r Date Additional Comments: I ❑ Stk 466 6781 ❑Lodi W-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT Np. t EH 13- 241 REV. tilt 5l � �EH 14-29