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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE_ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) I 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. + Job Address —Z S 7� /�f��i�]�t.�1 City Lot Size PM F Owner's Name � Aa - Address Phone Contractor y Address `— License No.3"�, 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i`} Public, ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout' I I i Irrigation —.Approx. Depth 1 I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter W Sealing Material flop 501 Depth Filler Material-(Below 50'1_ TYPE OF SEPTIC WORK: NEW INSTALLATION V_REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence ' 4-- Commercial_ Other Ott. + t i i t Number of living units: _-_� Number of bedrooms_� � k =e o r Character of soil to a depth of 3 feet: P Water table depth SEPTIC TANK L'Type/Mfg _77"Cap—i6tyNo. Compartments PKG, TREATMENT PLT. ❑ Method,of Disposal Distance to �Barest: Well 1 Foundation c 5 Property Line i 0 f df LEACHING LINE ZKNo. & Length of lines Q' Total length/size, FILTER BED ❑ Distance to nearest: Well i FoundationProperty Line T ` 1 SEEPAGE PITS 1.4— Depth Size Ra , Number SUMPS 0 Distance to nearest: Well 1 ' Foundation_- 737L Property Line l f i DISPOSAL PONDS ❑ 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: "I certify that in the performance of the work for which this permit is issued, I shall not 9� I employ any person in such manner as to became subject-to-workman's compensation laws of California." Contractor's hiring or sub-contracting signature f 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 m t call r all re re inspections. Complete drawing on reverse side. I { Signed X Title: © Ala I Date: ? 4 f 1 $ FOR DEPARTMENT USE ONLY } w. Application Accepted by Date' 7 Area Pit or Grout Inspection by Date m 'Final Inspection by Date z �� Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104` ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental tHealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. i +.EH 13-24(REV.1/851 EH 11-2e ,) �'�.�.