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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �0 Fy Telephone (209) 466-6781 i. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E " (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 Distrirr Ski ` AiP N i Job Address ss-o City S CQ01)Lot Size 3 P<rZ .3 PM Owner's Name t ' '1 �Q f y y-S `� S Address `-� � ! TA 0 - Phone `t Contractor A�U�rjcAs N ld� CMZ License No. p�_ Ll Phone qg TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 "DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE .._ „ I 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 a ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑.Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ CJ Irrigation --Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. - "State Work Done t i C' Well Destruction '�WO Well Diameter Sealing Material atop 501 '" / Depth Filter Material {Below 501 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 Commercial Other i{ Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: 6 Water table depth SEPTIC TANK ❑ Type/Mfg C� Capaci �2tD No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation �� Property Line (; LEACHING'LINE ❑ No. & Length of lines r C'P0 length/size r FILTER BED ,;' 1:1 Distance to nearest: Well Foundation Ste— Property Line SEEPAGE PITS ❑ Depth Size Number -e SUMPS t'i ❑ Distance to nearest: Well 300 Faundatiori 60 Property Line DISPOSAL PONDS =1� ❑ ` 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 Iicens_ed 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 lawsof C flifornia." - The applica /rust call for al it inspection . Complete drawing on reverse side. Signed X ry Title- �il�� r Date: EPARTMENT USE ONLY . -111,,. on Acceptsd,'�by Date ^30 Area M, Pit or Gr i Inspection byOt A. Ana � Final inspection b +A Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 8356385 4 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2063, 5tk-, CA 95201 ' h FEE AMOUNT DUE AMOUNT REMITTED CASH' RECEIVED By DATE PERMIT NO- INFO f r EH 13-241REV-11A51 - "" EH 14-28