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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'YEAR FROWDATE 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 R4Ies and Regulations of the San Joaquin Local Health District: E US l N!L- M I_W tAlAe `+ ndf Job Address City Lot Size 5- Zr '`r PM Owner's Name Address 1,91Z17 &9W Phone 474" S - 4 Contractor Address ?O. License No. Phone �' p —TYPE-OF"WELL/PLUMP ""°"NEW'WECL ❑"—� WELL REPCACENIENT ❑-- ---DESTRUCTFON C]' PUMP INSTAL. 4 _ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK t --SEWER LINES s DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PlTSISUMPS INTENDED USE TYPE OF WELL PROBftM AREA CONSTRUCTION SPECIFICATIONS � ❑ Industrial ❑ Open Bottom I] Manteca Dia..of Well Excavation Dia.,of Well Casing ❑ Domestic!Private El Gravel Pack ❑ Tracy Type of Casing ; a _ _ Specifications h ❑ Public ❑ Other 9-Delta .,_,.--•--�Depth•of-Grout �eal�N "^'`'�` '� �Type�Grout�, �,❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed,bv-�s : State Work Doner Repair.Work Done ❑ Type of Pump t H.P. _ �._ � Well Destruction ❑,,-Well-Diameter.- ' Sealing Merial-{top Depth - _ _ s r r Filler€Material ( low 50'1 "�f TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION O DESTRUCTION 0(No-septic system permitted if public sewer is - f �, available within 200 feet.? Installation will serve: Residence-X Commercial— Other a G Number of living units:-_L----Number cf-bedrooms Character of soil to a depth of 3 feet: -Z Water table depth SEPTIC TANK ■ Type/Mfg I .3 y ('Capacity l z,DA No. Compartments -----�r ..---.-�tI---- Method of Disposal " PKG. TREATMENT PLT. ❑ Distance to nearest: Welll VA2 Foundation 30 Property Line J-OA2�— I a - I LEACHING LINE 1111111No. & Length of lines - ©0 Total length/size FILTER SED ❑ Distance to'nearest: Well ! Foundation Property Line SEEPAGE PITS - ❑ Xepth Size • G^ "` Number SUMPS ❑ Distance to nearest: Well 'Foundation Property Line I 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. ' r 1( s Home owner or licensed agent's signature certifies the followirig:r"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." F t `E The applicant must call for all required inspections. Complete drawing on reverse side. I 96 Date:` �� Title: Signed � � �' FOR DEP RTMENT USE ONLY Application Accepted by /� Date Area Q' Date Final Inspection by Date �u Pit or Grout Inspection by r C Additional Comments: . ` ^S� "`o 11 y1S �'l ❑ Stk 466-6781 El Lodi 369-3621 Manteca . 823-7104 ❑ Tracy 835 6385 y� �/(� ' Applicant Return all copies to: Environmental He Ith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Stk., CA 95201, FEE AMOUNT DUE q AMOUNT REMITTED CASH i RECEIVED BY DATE PERMIT"NO. INFO r7fi r `� i ��Lc,� �, �Lo•-1 n + EH 13-24(REV.1/851 /l/ EH 1426 y