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I ( 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. Job Address �o �7 �� City • �'fJ�GI¢ Lot Size PM___ Owner's Name ,4 �*G*e ` T� Address �o�� `��!�r&og Phone s L� Contractor /7 Address 00.4 R4 AV 09 License No. "/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ � -. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WECL — -- 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 Pad k ❑ Tracy Type of Casing_ Specifications Fl Public ❑ Other .'t ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _Approx.:Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump:.–.'---- t ,-1 H.P. State Work Done Well Destruction"❑"�Well-Diameter Sealing Material (top 50'1 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION fe REPAIRlADDITION I 1 DESTRUCTION I 1 (No septic system permitted it public sewer is { available within 200 feet.) Installation will serve: Residence/— Commercial— Other € Number of living units: _>� Number of bedrooms _.__ No J Character of soil to a depth of 3 feet:'rI ? Water table depth SEPTIC TANK . Type/Mfg ' ?�' C' f I Capacity 1200 No. Compartments PKG. TREATMENT PLT. ❑' I .e .. _�Method--of-Disposal Distance to nearest: Well Foundation i7 Property Line jam` LEACHING LINE, 0.. No. & Length of lines 1 ......___ Total length/size— FILTER ength/size FILTER BED L1 Distance to nearest: Well C ` Foundation =01 Property Line SEEPAGE PITS i 1� Depth Size _ Number SUMPS ClDistance to nearest: Well Foundation Property Line DISPOSAL PONDS LJ � E { 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 t rules and regulations of the San Joaquin Local Health Di"strict. 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 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." I The applicant m t t call for ail required inspections. Complete drawing on reverse side. Signed X Title: Date: OR pEP RTMENT USE ONLY Application Accepted by Date i Pit or Grout Inspection by Date Final Inspection b Data i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 3 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 RECEIVED BY DATE PERMIT NO. ♦.EH13-24(REV,1/B5) 1 w EH 14-26 - !s 1 4 . n