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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. Job Address City 1 409 Lot Size /r �d � PM _ 7(� Owner7's Name Address 062 / � /fie✓ �^�/ Phone Contractor /4 lE�Y�/�!�Address License No,?U57i Phone *a/ 33 TYPE OF WELL/PUMP: NEW WELL ❑ W LL 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 I'3 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I i Irrigation __ Approx. Depth t I 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 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I' DESTRUCTION I 1 Mo septic system permitted if public sewer is P - available within 200 feet.) Installation will serve: Residence_ Commercial Other •wl Number of living units: Number of bedroo s � — r Character of soil to a depth of 3 feet: A, -- Water table depth SEPTIC TANK ❑ Type/Mfg 6F Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L_�—No. ✓it Length of linesTotal length/size FILTER BED ❑ Distance to neo est Well Foundation Property Line t . , Srmp, E PITS Depth _ Size Number �4 Distance to nearest Wel Foundation Prroperty Line J /49 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 i rules and regulations of the San Joaquin Local Health Di"strict. 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." Contractors 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 call for all squired inspections. Complete drawing on reverse side. Signed X Title: j0jW,0 e k Date: /;--�_Oef FOR DEPARTMENT USE ONLY Applic ion Accepted by Date �r � Area or rout In ction by Date . Final Inspection by Dat —112- 2 a� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 `011 11 s, 2 FEE INFO AMOUNT DUE AMOUNT REMITTED I CA H RECEIVED BY DATE PERMIT'NO. ♦,EH13-24(REV.i rj /) / 70 EH 14-26 CF jJ 6'�c�f