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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. p ?,O, Job Address i� S +/r/o n 'S 0 S a 11 Aid--- - City Lot Size PM Owner's Name S e L D 11/K6 rJAddress Phone Contractor��tf 1[�1� Address_ SOY 1�(`] License No. �A 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 l'l Public f.f Other n Delta Depth of Grout Seal Type of Grout _. I Irrigation —_Approx. Depth i I Eastern Surface Seal installed by _ �A Repair Work Done ❑ Type of Pump H.P. State Work Done_ Q Well Destruction ❑ Well Diameter Sealing Material (top 50'I p t Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION t I DESTRUCTION I I INo septic system permitted if public sewer is `I',' � available within 200 feet.) Installation will serve: Residence Commercial _ Otherj Number of living units: ; Number of bedrooms 14 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ild Type/Mfg Pd-� 112-0y7G/ZCapacity aLZ_� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation CIO Property Line -2o ° LEACHING LINE No. & Length of lines a0 4 Total length/size L40 6C FILTER BED ❑ Distance to nearest: Welt 15A. Foundation :3 0 t Property Line SEEPAGE PITS i I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property.Line- 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. 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." The applicant must call f r all required 'ns tions. Complete drawing on reverse side. J Signed h U X Title: �� Date: { G ` FOR EP TMENT USE ONLY Application Accepted by Date / Area Pit or Grout Inspection by Date Final Inspection by '� Date Additional Comments: ❑ Stk 466-6781 EJ Lodi 369-3621 0 Manteca 823-7104 Cl 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 PATE PERMIT NO. INFO CASH +.EH III&I REV.1'/_.51 EH 14-26 !3 ��