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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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. ],, r,�L` Job Address 4 S . c66 • �7 e«' E>Nef City �1.- Lot Size I I L ft!�* Pm 1� 1r`? M�W1 �>PP Address � "G , f Phone 9vy r�g� �I Owner's Name - 1 Contractor's Name �SC�1a-p— License No. �38C?3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT! N ❑ SYS EM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL D.__ PROP. LIN r I FOUNDATION -"` AGRICULTU WELL OTHER LL PITS/SU PS INTENDED USE TYPE OF ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /Dia. Well ❑ industrial ❑ Open B orn ❑ Manteca Dia. of Well Excavation Casing❑ Domestic/Private C7 Grav Pack O Tracy Type of Casing ns ❑ Public ❑ Ot r ❑ Delta Depth of Grout Seal _ out f ❑ Irrigation �_ pprox. Depth ❑ Eastern Surface Seal installed by— Repair y Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material [top 501 t Depth. Filler Material.[Below 50'i'__~^ ad TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION - DESTRUCTION ❑ (No septic system permitted if public sewer is �- available within 200 feet.) Installation will serve: Residence X__ Commercial Other Number of living units: / Number of bedrooms 1 r 11 ;` Character of soil to a depth of 3 feet: C.1 Mr1 a .Water table depth ( 9 SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line e LEACHING LINE It No. & Length of lines - 410 Total length/size_ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ef Depth Size� L umber- SUMPS JK Distance to nearest: Well/&OJ- Foundation� Prope4y Line f 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 lays,and ; rules and regulations of the San Joaquin Local Health District. ri 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."Contractors hiring or subcontracting 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 Calif nia." i The applicant f c for all re uired ins ctions. Complete drawing on rev a side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application;Accepted by �-�" � • Date �. 3 'U 1 Area ' �7 Pit or Grout Inspection by Date Final Inspection by ' U��_ Date' Py Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. i 1 INFO CASH + EH13-24(REV.10183) J .. �` RZ— EH 1426 1