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APPLICATION FOR PERMIT "` SAN JOAQUlN 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �® O City -�-- Lot Size PM Owner's Name �4;7t / �• �� Address Phone Contractor -TJ"4; R �.: ddress� 'n7��7 A2!" "icense No. /Oyo(�__Phone ��-3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P. LINE FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONCATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. xcavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i f'1 Public ❑ Other lta Depth of Grout Seal Type of Grout I I Irrigation _ �-Approx. Depth { I Eastern Surface Seal Installed by l Repair Work Done ❑ !Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 501 V" k Depth Filler Material (Below 50') ' TYPE OF SE ,liC WORK: NEW INSTALLATION I REPAIR/ADDITION I l DESTRUCTION I 1 (No septic system permitted if public sewer is �. I, available within 200 feet.► I Installation will serve: Residence_ Commercial X Other o i X Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: / eWater tabldepth SEPTIC TANK N Type/Mfg 1 . ..2°' rrr Capacity SCD L/No. Compartments r[� PKG. TREATMENT PLT. ❑ Method of Disposal Q r Distance to nearest: lWT a Foundation Property Line LEACHING LINE ❑ No_ & Length of tines y ��e7 l+�!�' Total length/size [l�f FILTER SED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 04 Depth a-?S Size �� Number Y i 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 i rules and regulations of the San Joaquin Local Health Di§trict. ' 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 t 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 0 uir inspec ons. Complete drawing on reverse side. ef Sign - Title: e2lL. 4C - ^mm Date_ OR DEPARTMENT USE ONLY Application Accepted by Date 3 Area Pit or Grout Inspection by Data rFinal Inspection by Date 3 Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE O AMOUNT DUE AMOUNT REMITTED K RECEIVED 6Y IDATEr PERMIT NO. +.EH13-24IREll,iin51 0.1b D�"' EH 1428 v F