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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 Rules and Regulations of the San Joaquin Local Health District. Job Address CityG Lot Size PM G *t Owner's Name D �d � Address 7— A � C Phone Contractor Z�?&1-� Address ! License No. 7b._ �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENY ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SE NK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL . OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ACONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o-W xcavation Dia. of Well Casing ❑ Domestic/Private' ❑ tsravel Pack ❑ Tracy Type of Casing Specifications ❑ Public n Other ❑ Delta YDepth-of Grout Seal Type of Grout ❑ Irrigation " 1pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ' ❑ Type of Pump H.P,1 ' State Work Done_ Well Destruction ❑ Well Diameter Sealing Material {top 50') " t Depth Filler Material IBelow 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is r available within 200 feet.). Installation will serve: --Residence`.4� Commercial— -Other Number of living units: 4— Number of bedrooms 1 i Character of soil tb a depth of 3 feet. D , Water table depth de SEPTIC TANK t LDType/Mfg �� Capacity _ Na. Compartments PKG. TREATMENT PLT. ❑ �ff Method of Disposal€ Distance to nearest: Well A00 `TFoundatidn:� Property Line 4 b �T r o --ti ��;,,� A LEACHING LINE i " No. & Length of lines rgth/s - To�tat��e'nize FILTER BED ❑ Distance to nearest: Well Foundation — Property Line f SEEPAGE PITS 11;i( Depth Size " ' Number SUMPS El Distance to nearest: Well ZAV 10 Foundation� Property Line .— DISPOSAL PONDS.': ❑ r� 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: "I certify that in the performance of the work for which this permit is issued, l 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." ) The applicant must call for aliyaquired inspect; ns. Complete drawing on reverse side. . i Signed X " �� t7� — Title _�� Date: FOR ARTMENT USE ONLY � r �� U Application Accepted by Date Area Date Additional Pit or Grout Inspection by Date Final Inspection by , i. Additional Comments: ❑ Stk 466-6781 i ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUIVT DUE AMOUNT-REMITTED- - -CK#._ ^'^ 'RECEIVED Sy— " ' -DATE 'P�AMIT'NO _ T INFO' GASH -+ a1 EH t3-24(REV. - EH1428