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l s 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. I Job Address l /aN City 4& A Size G 1 I Owner's Name��4hV iV d Address �1/ �5/�lQ"'J, Phone Contractor Address License No. r-Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Z942 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 ("1 Public Cl Other f7 Delta ti Depth of Grout Seal Type of Grout I I Irrigation __._Approx.+.Depth I I Eastern s,, Surface Seal Installed by 'Repair Work Done. -El- "Type of Pump. H.Ill State Work Done Well Destruction ❑ Well Diameter , Sealing Material (top 501 0 Depth - f _ Filler Material I8elow 50') EE TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms T Character of soil to a depthof 3 feet Water table depth r/10 Q_ SEPTIC TANK l❑ Type/Mfg` Capacity/-A"& — No. Compartments PKG. TREATMENT PLT. ❑ el "~ Method of PLsposal Distance to nearest:— ell Foundation� Property Line � LEACHING LINE ❑ No. & Length of lines Total length/sizef FILTER SED ❑ Distance to nearest: Welles Foundation ,/ ( PropertyLine ef'e SEEPAGE PITS 11 Depth { Size _ Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 t call for a1 a 'red ins tions. Complete drawing on reverse side. r Q Signed X Title: -��1.L/�i' / - Date: ENT USE ONLY DEPARTM Application Accepted by Date Area 49/tf Pit or Grout Inspection byDate Final Inspection by Date a Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO. + EH 13-211REV.1/955 ® /}e- od 4-26 [(/ G�r_ EH 1