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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA j 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 -S E /yleJ/eSE City "DZ Lot Size elDAG PM I Owner's Name 1-E- Address .57AWe Phone i Contractor_r` t�Ya E• yj/&oD_ Address License No. ��Sa-7G -Phone s"397/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private D.Gravel Pack ❑ Tracy Type of Casing Specifications - .I F1 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation __."Approx. Depth I Eastern Surface Seal Installed by _41- Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Seating Material /top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1l REPAIR/ADDITION DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence V/Commercial— Other Number of living units: -.-/-- Number of bedrooms Character of soil to a depth of 3 feet: r_ i '4'K SAID 5e Water table depth SEPTIC TANK ❑ Type/Mfg J5 X 0 AG Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines lee Total length/size 'y iX Z FILTER BED ❑ Distance to nearest: Well Foundation I Property Line SEEPAGE PITS l Depth �� Size '¢ Number SUMPS - ❑- Distance to nearest: Well_/A24a__L Foundation /A.S 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,'l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Xcz:a of Title: Date: FOR DEPARTMENT USE ONLY A plication-Accepted by Date i or Grout Inspection by ate I/ Final Inspection by- / j/2 Date Date Additional Comments:' LI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ ,t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Silk., CA 95201 \[[��►` FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH13.24(REV.tiesr _70 db EH 14-26