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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. f Job Address / Qa 5 '"• 80 _ City Lot Size PM Owner's Name L Address SW 5b. ,N, 5 '-Q-V Phone 1 (0 Contract Address ;O• �� License No-� � � Phone 5 K 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 Dia. of Well Casing El Domestic/Private ❑ Gravel Pack C1 Tracy Type_of Casing Specifications_ � _ _ l / 0ublic ,❑ Other ❑ Delta Depth of Grout_Sea! Type of Grout .� ❑ Irrigation '�� __J4pprox. Depth ❑ Eastern Surface Seal Installed by ^' Repair Work Done—[]-- of Pump -H-P:`- -' - -- -Stafe Work Done ^ �""" Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth # i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial .X Other +J ;t 3-q Number of living units: Number ofdrooins UUU 90 Character of soil to a depth of 3 feet:SEPTIC Water table depth SEPTIC TANK �Type/Mfg r Capacity_ -1-2 — No. Compartments PKG. TREATMENT PLT. ❑ � F .. 1 f r Method of Disposal. Distance.to nearest: l Well 100 '4' Foundation 16 Property Line_ b ` length/ ' LEACHING LINE No. 8, Length of lines. < <Total len 9t 9 , FILTER BED ❑ Distance to nearest: Well IbO Foundation—I� Property Line S ti th SEEPAGE PITS 0' Dep ? Size 3 Number _ i SUMPS ❑ Distance to nearest:` Weil�_ Foundation _. Property Line r DISPOSAL PONDS ❑ i 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. i^ .i.. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permt s issued, I shall not ! employ any person ln.such manner_as.to.become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I dertify 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 applicantst call for all uir inspections. Complete drawing on reverse side ^ ,.._ Signed —e (r} Date: .:.��.. �P �FOR Title:DEPARTMENT USE ONLY i Application Accepted by Date & Area Pit or Grout Inspection by Date =inalnspection by Date f Additional Comments: ❑ Stk 466-6781 L7 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED (CK# RECEIVED BY DATE PERMITNO. INFO ASH EH13-24(REV.1/05) EH 1428 , +