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APPLICATION FOR PERMIT r : SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED , Q (Complete in Triplicate) NJ 1h �� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the rk he in describe 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 / Cit Lot Size 41P 4�7/00 d PM Owner's Name L /7/J�ZGT nLA�dl ,sOLiIlrPss �/ 4.f r.,�,,,� tC,� aY oy — .2 D ------------•- Wafer Supply: Public system 4 -evMmunify system ❑ Private ❑ Depth to Wafter Table 413 ft. f^.I,A�aet•nr n; a 'I 1 _1 ] I,.1. C__ _I n � , n � TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑^ DESTRUCTION ❑ PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO LINE FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications ❑ Public ❑ Oth CI Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by Repair Work D ❑ Type of Pump H.P. State Work Done Well D ction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 �h r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONI INo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ Na. & Length of linesTotal length/size Q FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L� 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 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." Thea licant must call for all required inspections. Complete drawing on reverse side. r t Signed X Title: Date: F DEPARTMENT USE ONLY � r (� Application Accepted by _� �,AX Ql►l ��•�, Date d^-�^ li"7 ��A�rea Pit or Grout Inspection by Data Final Inspection by `'1/t`� Date —F— Additional Comments: ?1-15 hPP TV RC U9UmL LI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy .835-6385 \ :� " FDU 1U0�{!u 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 G 5 RECEIVED BY DATE PERMIT'NO. + EH 13-21(REV.1i95) �s~U 14-20 EH l