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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON AVE., STOCKTON, CA Telephone-(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 I 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. F I Job Address �S tA 544. City cL rzt :.Lot Siz PM I Owner's Name Address �] 5� LOC CJi1 — Phone -7Y,9,34v-24" c� �36 5'7,1f X: Contractor's Name License No. __ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION. ❑ PUMP INSTALLATI-ON '❑ -SYSTEM REPAIR" ❑.. OTHER"❑; Cl�i i 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 c' S ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications Cl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout RRR ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 Depth Filler Material [Below 501 x 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 , F� Number of living units:_11— Number of bedrooms Character of soil to a depth of 3 feet:—64 6A4 Lt,4nn Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Propefty Line LEACHING LINE ❑ No. & Length of lines Cl ��1 Total length/sized f FILTER BED ❑ Distance to nearest: Well rl_ Foundation S� i Property Line t� �^ i e SEEPAGE PITS ❑ Depth _ 1 A Size t w M'L t o 1 Number ' SUMPS I[YDistance to nearest: Well —I Foundation 161 Property Line /U 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 sybject to workman's compensation laws-df 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 for all r uired inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date - ` Area Pit or Grout Inspection byDate Final Inspection by Date ! Additional Comments: ❑ Stk 4665781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 11 Tracy 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ak e., P.O. Box 2009,'Stk., CA 95201 FEE AMOUNT DUE 'AMOUNT REMITTED CK RECEIVED BY DATE; PERMIT`NO. INFO CASH + €H 13.24(REV.10!63) -7 #1196 EH 14-26 i