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APPLICATION FOR PERMIT # SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 -i 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 welUpump and the Rules and Regulations of the San JPaquin i Local Health District. Job Address City Lot Size Z� ��Pah�S__ PM Owner's Name �- Address r✓ �' 'Uhone "3G3 Contractor r" �`1C- f�G� Address S � �Gnse No.L��aG Phone -� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION 0 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 e ,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Li Other r Delta Depth of Grout Seal /Type of Grout — I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by - r i Repair Work Done LJType of Pump H.P, State Work Done ' X , Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (31W w 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION ("I REPAIR/ADDITION A.,DESTRUCTION I i INo septic system permitted it public sewer is available within.200 feet.) Installation will serve: Res deuce Y Commercial Other Number.of living nits: Number of bedrooms- Character�of'soil to a depth of 3 feet: 'A/V Water table depth r t f1 SEPTIC TANK Type/Mfg J Capacity 2�U �, No. Compartments 1r " PKG. TREATMENT PLT. ❑ Method of Disposal -sem r Distance to nearest: Well C o Foundation=T/ Property Line-7 LEACHING LINE j No. ✓3r Length of lines 2 Total length/size FILTER BEDS ❑ Distance to nearest: Well Foundation —_ Property Line SEEPAGE PITS i I Depth Size ' Number SUMPS ❑ 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'bertifies 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." The applicant must c Il for all/ wire&pections. Complete drawing on reverse side. Signed X Title: Date: 4. r � FO EPARTMEN -ONLY ' Application Accepted b Date�J �14—tC1 1Area � CCCJJJ Pit or Grout kasp ction by bate Final Inspection by Date —� Additions!Comments: J .❑ Stli 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&385 „''Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO I ,( + EH 13.24(REV.I1 5) ` f �,.13 /t sf 4071, EH 14-26 u'