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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 horeby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District, Job Address 42$d /31,/JSff�� 7P City S" Lot Size PM Owner's Name Rj!_ l 'a -E) '4.en ✓ Address S dS i ,Phone Contractor 1a �• GJc w_,D Address License 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 Dia. of Well Excavation - I Dia. of Well Casing 1\ Q Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications I`7 Public i•1 Other 'f CI'DOCU "-DeptK df Grout Seat Type of Grout _ I I Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work.Done D Type of Pump . H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION I I DESTRUCTION I I (No septic system perrr)itted if public sewer is available within 200 feet.l Installation will serve: Residence-,/Commercial Other Number of living units: _)E� Number-of bedrooms- Character edrooms Character of soil to a depth of 3'feet: __ G-�[S/ Water table depth C-1 SEPTIC TANK ❑ TypeIMfg U Capacity_ _J l<raa No. Compartments PKG. TREATMENT PLT. ❑ f Pu GIG U1,472�_/_D � Method of Disposal Distance'to-nearest: Well Foundation Q Property Line A, ' - LEACHING LINE No. &'Length of lines Total length/size e '�V FILTER BED ❑ Distance to nearest: Well1A Foundation 2-,9 Property Line $ SEEPAGE PITS I' Depth y �-��_ Size_ 3 `� _ Number _31 SUMPS Ll Distance to nearest: Well *A Foundation___ d Property line S 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 Sari Joaquin Local Health District. Home owner or licensed agent's signature.6ertifies the following: "t 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 must call for all required inspection .=Complete drawing on reverse side.. Signed X,__� x. Title: —G` Date: Z-17-01 QR DEPARTMENT USE ONLY Application Accepted by — Date -7 APP rea Pit or Grout Inspection by Date r�� 't+Final Inspection by Date Additional Comments: ❑ Stk 466.6781 r ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pelrmit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4f CASH RECEIVED BY DATE PERMIT'NO. •.EH 1144-28-24.tREV EH .tin 51 r7a 0_0' W