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APPLICATION FOR PERMIT 1 f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED Ile (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/ um and the Rules and Regulations of the San J Local Health District. p p e9 Joaquin Job AddressR06 ` �'11 City Lot Sire PM �(v N� Owner's Name O Address ,b dr � L`'t 'J Phone ai' Contractor � Address License Na.,iC�LS_,��,L__Phone TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I 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 ' " 13Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private i ❑ Gravel Pack! ❑ Tracy Type of Casing Specifications [D Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout j ❑ Irrigation .—Approx. Depth ❑ Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth I ! Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence, Commercial— OtherQ 4t.+ Number of living units: A_�_ Number of bedr Character of soil to a depth of 3 feet: Ab - L.6A Water table depth SEPTIC TANK 6Y Type/Mfg O - (A.� C Capacity No. Compartments L- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:earest: Well r _ Foundation 5 f Property Line a � LEACHING LINE IIY No. & Lengtkh of lines Total length/size--YO r FiLTER 8ED ❑ Distance to nearest: Well.. a)'d r Foundation r_ Property Line__.�0� SEEPAGE PITS E4-'Depthf i �.. $ize Number SUMPS ❑ Distance tonearest: Well �- r X65 Foundation .5f Property Line DISPOSAL PONDS ❑ E 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 pentons subject to workman's compensa- tion laws of California." a The applicant must cap rail re ire inspections. Complete drawing on reverse side. Signed Title: 60 A) A Date: � _2 3 I FOR DEPARTMENT USE ONLY Application Accepted by z Date Area Pit or Grout Inspection by Date Final Inspection by Date G Additional Comments: ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 8354M Applicant- Return all copies to: Environmental Hbalth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E I l FEF INFO CASH DATE PERMIT'N0.AMOUNT DUE AMOUNT REMITTED CR RECEIVED BY EH laze(REV.iiss)