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APPLICATION FOR PERMIT SAN JOAQUIIN 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) 4 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District.[ Job Address `� OZ IL� City �I Lot Size / PM Owner's Name Address Ph r w I L one ^�/ Contractor y` L_a Address 6A& Lit ,(557.2 ,7(pO39�� cense No. 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 PITSISUMPS 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 1-1 Public n Other n Delta Depth of Grout Seal Type of Grout _ I i Irrigation _Approx• Depth l I Eastern Surface Seal Installed by Repair Work Done - ❑ Type'af Pump - H.P. Stete'NVork f]one_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence-Commercial— Other w Number of living units: —I— Number of�drooms—3. Character of soil to a depth of 3 feet: A1 L d fif– f Water table depth SEPTIC TANK' - Ill Type/Mfg Capacity /G O7--, No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 7-5 f Foundation Property Line 90 j LEACHING LINT; ❑ No. & Length of lines Total length/size FILTH BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl _ 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 all for all p6quired inspections. Complete drawing on reverse side. Signed Xp Title:-� -N Dater /7-,21 47 ' FOR DEPARTMENT USE ONLY C i Application Accepted by bate_ Area Pit or Grout Inspection by Date Final Inspection by 0 Datefr7 J1 f � Additional Comments. _ ! ❑ Stk 466-6781 ❑ Lodi 3694621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 O L d tAMOU7NTDUE ��Gov FT 4 �a G TS r� pj. FEE AMOUNT REMITTED CKRECEIVED BY DATE PERMIt�NO.)NFD CASH+ EH 13-24{REV.1/A 57EH 14-28 - r