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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;_TON 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 Ryles and Regulations of the San Joaquin Local Health District. i Job Address /��' '�" City Lot Size PM Owner's Name Address- 1t yPUft_Ar-1 Phone �i`zs"1 I — Address 11.2 �Vlr.,�c � �u� License No. �-' aO Phone Contractor - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9- 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ___Approxi Depth ❑ Eastern Surface Seal Installed by t H.P. State Work Done -� Repair Work Done PType of Pump � �• Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.)- Installation will serve:I Residence_ Commercial— Other Number of living units: Number of bedrooms ` I table t Character of soil to a depth of 3 feet: Water_ _ i _'� :, ..��... �ah p SEPTIC TANK ter ❑ Type/Mfg' Capacity No. Compartments ` - r PKG. TREATMENT PLT. ❑ Method of Disposal 7,_ 11 } Distance to nearest: Well w Foundation Property Line LEACHING LINE ❑ No. & Length of lines '' t.. Total length/size- FILTER ength/size FILTER BED ❑ Distance to nearest: t.Well ..Y Foundation Property Line SEEPAGE PITS ❑ Depth y Size Number € SUMPS ❑ Distance to nearest: Well Foundation Property Line f 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 applicant m at call forA required inspections. Complete drawing-on reverse side. Signed X_ L +�' Title: ` Date: 'FOR EPARTMENT USE ONLY Application Accepted b Date f Area 2/r I E 01 Date Pit-or Grout Inspection by Date Final Inspection by i t ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 CASH RECEIVED BY , DATE PERMIT INFO I , EH 13-24(REV.i/05) � � �� f S 013 I f 3 I /�J �/-137/ E14 14-26