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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. le i Job Address City 66_ Lot Size 3/ I 64--ly- PM Owner's Namt^e-+JJIL.[_ _ t�l �X�IIS Address Phone 4`7 -0709 Contractor C"'C[]s, 4ddress 71. U jlb!eC5(7_License No.!�'?W2 Phone 9 TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Cl Tracy Type of Casing Specifications FI Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 \ TYPE OF SEPTIC WORK: NEW INSTALLATION 1W REPAIR IADDITION l 01=STRUCTION V(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Ae!� yCommercial_ Other Number of living units: _J_ Number of bedrooms S Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1R0"`Type/Mfg G _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal' Distance to nearest: Well Foundation Property Line LEACHING LINE $o,"No. & Length of lines X.VC) Total length/size !-� r FILTER BED ElDistance to nearest: Well Foundation Property Line as SEEPAGE PITS I ! Depth /01 Size x I Q r Number SUMPS c Distance to nearest: Well Foundation - ;!d ` Property Line S DISPOSAL PONDS C 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. f 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 st call for ail required inspections. omplete drawing onreverse side. Signed X Title: '(/ 124 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ZQ ��f,` Area Pit or Grout Inspection by Date // f Final Inspection by Gam/► Date Additional Comments: G X4 Com _:5 ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 Tracy 835 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE K 11 INFO QfAMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY ` DATE ] PERMIT'NO. EH 3-24{REV.i/H51 117 76-Q—) .}� EH t4-26 L.L/ t