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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4Complete 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 12 ®� 1, 1 i C i4 city C �O 41 Lot Size PM f�Q�' �j ' 3 3 Owner's Name i'1i/,� r/�� I7`� Address Phone -&38 I Contractor sName^ Gf_ License No. { �.C ~.,-._ Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT"❑ Jr. DESTRUCTION ❑ e PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 ,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/Privaie ;, ❑ Gravel Pack ❑ Tracy Type of Casing Specifications LTO Public ❑ Other ❑ DaltaDepth of Grout Seal Type of Grout F ❑ Irrigation --LApprox. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ❑ QTipe of-Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 T-1 r,Depth j Filler Material (Below 501 i TYPE OF.SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X DESTRUCTION ❑ (No septic system permitted if public sewer is 9 I I available within 200 feet.► Installation will serve: Residence_ Commercial ^ Other } Number of living units:0 Number of bedrooms a j Character of soil to-a depth of 3.feet: �.1 +r0 Water table depth SEPTIC TANK f7l Type/Mfg Capacity ZTO 0 No. Compartments I PKG. TREATMENT PLT..❑ i �'�'� I Method of D'sposaI� ` t � ,"� ,�, ,Distance-to nearest: Well & Foundation /0 Property Line i 3 LEACHING LINE t �} '"3 2 —7 0 rT em .L�.i. 410 � � SNo:& L^ength-of lines � '�`otal length/size FILTER BED ❑ -Distance to nearest: Well )® Foundation �® Property Line-O f SEEPAGE PITS pDepth Size Number SUMPS , - -6 , Distance to nearest: Well.. Foundation's Property Line DISPOSAL PONDS tEl --• I hereby certify that I have prepared this application and that the work will he 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 iii 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-contradiltig signature I 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 Californi The applicant must a for all rELquired inspections. Complete drawing on reverse side. r Signed Till.- Date: J 4{ FOR DEPARTMENT USE ONLY t Application Accepted by Date Area 0 GT F T Pit or Grout Inspection by ;Date Final Inspection by Date Additional Comments: ❑ Stk 466-Mi ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT OUE"" 4MOUNT'REMITTEQ CASH--RE CEIVED'6Y • -DAT7=lam" PERMIT'NO.- +EH 13-24(RW 10/03)' N� l_fl—�Tfi �II EH 14-26 V,