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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 TYEAR 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 ! /� � iGF "'�' City L 1 Lot SizePI1A Owner's NM,.� Address Phone acfi� / S �s `T contractor Address,!:�,�7&/ , �Tl iGd�'Cic e No. ! Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL 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 pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications V 1-1 Public ❑ Other Cul Delta Depth of Grout Seal Type of Grout v I I Irrigation _..Approx. Depth I I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') �-- t Depth Filler Material (Below 501 TYPE OF'SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available.within 200 feet.) 1 Installation will serve: ResidenceX Commercial— Other1 Number of living units: __/_ Number of bedrooms -3 a f Character of soil to a depth of 3 feet: Oz Water table depth SEPTIC TANK i Type/Mfg Capacity ` l�Z No. Compartments P PKG. TREATMENT PLT. ❑ r-� r Method of Disposal Distance to nearest: Well `-�`� Foundation Property Line �75� d 1 LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well /( Foundation Q1'� Property Line ✓" SEEPAGE PITS �. Depth Size Number � SUMPS Cl Distance to nearest: Well Foundation._� Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordante 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, 1 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 pe rmance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The appli nt ust c I or all req r-0 i do . Co plate drawing on ars side. AA f� Signed Title: � �K/C- Date: � v FOR DEPARTMENT USE ONLY Application Accepted by Date y T ! Area a or Grout Inspection by "` � Date 2E 2Final Inspection by Date A itional Comments: `"i�t'f� Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 Abplicant- 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 (CK ff RECEIVED BY DATE PERMIT'NO. + EH 13-24IREY.iin51 ® '�U. 06 1LF� EH 14-26lJ 11