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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 Ryles and Regulations of the San Joaquin Local Health District. 10 �i Job Address l0, d.; City Lot Size CLt-04 rdae PM Owner's Name ddressl�{ �o Phone ' Q Contractor Address l. ��V License No�7�3�3 Phone 7 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 _ 0 Domestic/Private :1 Gravel Pack ❑ Tracy Type of Casing Specifications � ❑ Public ❑ Other C Delta Depth of Grout Seal Type of Groat J) ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Stgte.Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') W Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) CQ Installation will serve: ResidenceCommercial— Other Number of living units: _-L Number of bedr oms Character of soil to a depth of 3 feet: QA/ Water table depth 12 ,0 SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments PKG. TREATMENT PLT. F- Method of Disposal Distance to nearest: Well �1Foundation Property Line LEACHING LINE No. & Length of lines �Vy , Total length/size FILTER BED ❑ Distance to nearest: Well Foundation .10 Property Line U SEEPAGE PITS C 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 certifies the following: "1 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 subcontracting 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 m2talfor all requireclli inspecti Complete drawing on revs .id fj Signed PffTitle: Date: Af FOR DEPARTMENT USE ONLY Application Accepted by Date t O Area Pit or Grout Inspection by Date _.._. Final Inspection by Data Additional Comments: t5— ( W ❑ Stk 466 6781 ❑ Lodi 369 3fi21 ❑ Manteca 823 7104 ❑ Tracy 835-6385 Q—Z'L—ffs 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 CASH CK RECEIVED BY DATE PERMIT'NO. + EH 1 -24(REV.i 8 5) ) , EH 14-26 " J 1 O�S/� k-S I�y S (J }.� O(--A