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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZELTON AVE., STOCKTON, CA i ' 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 Addres } - 4u� City Lot Size PM Owner's Name Address , Ll114,4A Q. Phone Contract r Address bLicense No.Jo(D7�}U{�'^1�lt / W 2(D Phone. SCIS' .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLO.- PROP. LINE q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS 1 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation 1Dia..-of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing {Itk. Specifications F1 Public Fl. C] Delta Depth of Grout'Sea~ "'" ""` • �. ype of Grout _ I Irrigation __Approx!Depth I } Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pum — - w YR R H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth ler Material (Belo 50')' TYPE OF SEPTIC WORK: NEW INSTALLATION IJ EPAIR ADDITION I DESTRUCTION I 1 lNo.septic systemrpermitted it public sewer is f "^ available within 200 feet.) Installation will serve: Residence' 'Commercial_ Other Number of"living units: Number Abedrooml ' - -Character of soil to a depth of 3 feet: s r" Water table depth SEPTIC TANKrType/Mfg j` ` r+ `°t Capacity No. Compartments PKG. TREATMENT PLT. ❑ ^" e" Method of Disposal Distance to nearest: Well I ! FoundationProperty Line A� , LEACHING LINE i[1 No. & Length of,lines Total len th/size FILTER BED ❑ Distance to nearest: Foundati Well f Car � ` g r 4� on _Property Line SEEPAGE PITS I I Dopth -Size X � - Number SUMPS V4-- Distance to nearest: Well-40- Foundation_LQ r Property Line _. DISPOSAL PONDS ❑ i• I hereby certify that f 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. t 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." t The applicant mu all for all ui ed inspections. Complete drawing on reverse sid . Signed Title: Date: �C11 FOR DEP RTMENT USE ONLY / Application Accepted by Date L� Area 1 Grout Inspection by pate final Inspection by ate d itian mments: ❑ 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 1 FEE AMOUNT DUE AMOUNT REMITTED CK 01 INFO CASH RECEIVED BY DATE PERMIT"NO. + EH 13.21]REV.I i x sl U EH 11-29