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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.{'� Job Address ✓ ' Z,64 City Lot Size CM �G PM ,.,_Owner's Name ��e ` �G�74 Address 04—C." Phone Contractor 9f Address Illen WIT License No Phone � I TYPE OF-WELL/PUMP:..- _- _�, ,,, NEW WELL ❑_,,,,,,,_ WELL REPLACEMENT,❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ h OTHER ❑ ��r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 71 Public Cl 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 ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material 1Below TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.( Installation will serve: Residence Commercial_ O;her Number of living units: __Q_- Number of bedrno s Character of soil to a depth of 3 feet: S+ doom Water table depth SEPTIC TANK _Type/Mfg ��t:"')C1 L --Capacity Q._ No. Compartments a PKG. TREATMENT PLT. ❑ Method}of Disposal Distance to nearest: Well ' n� Foundation I Property Line tool- LEACHING no t LEACHING LINE ❑ No. & Length of lines `_" Total.length%size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ['I Depth Size _ Number ' SUMPS CI Distance to nearest: Well w Foundation _ Property Line 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. t 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 became subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 r ired - spections. Complete drawing on reverse side. i Signed X 1/ [.l. Title: Q,41+ µ Date: f DEPARTMENT USE ONLY r ! f Application Accepted by Date Area Pit or Grout Inspection by Date --- Final Inspection by Date Additional Comments: I I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca- 823.7104 ❑ Tracy 835-6385 ! ` Applicant - Return all copies to: Environmental Health Permit/Services"!601 E. Hazelton Ave., P.O. Box 2009, S1k., CA,95201 ' FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �7f CASH - + EH 13-24IREV.v/esl EH 14-2e 3 P