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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. PM Owner's r � City c.317 % _I"r of Size�y, �•L Job Address / f Owner's Name w` Address ��/�.5 �� Phone r 'r ,Q�t.,< 5 Contracts dress License No.l Z..1\ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r. 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 ` ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 — Depth Filler Material (Below 501 STALLATION REPA TYPE OF SEPTIC WORK: NEW INIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_46� Commercial_ Other Number of living units:_-,OL- Number of bedrooms Character of soil to a depth of 3 feet: Water table depth • SEPTIC TANK lY Type/Mfg 6454te apacity�`3e No. Compartments 1-- - PKG. TREATMENT PLT. El Method Method of Disposal Distance to nearest Well Foundation Property Line ,1 / 00 ` LEACHING LINE fZ_l4o. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well A Number Foundation Property Line s :_� C SEEPAGE PITS fiY Depth ,�`� Size r SUMPS ❑ Distance to nearest: Web o4pgj Foundation/QT>� Property Line ✓(� 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 subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." ps The applicant st 11 for`all,rtfquired.i pections. Complete drawing on reverse side. Signed X � �TL/fs`--� _ Title: Date: Ia v FOR DEPA TMENT USE ONLY r �1 /�.�� _� Application Accepted by--_,/ _ ¢B�tit/I Date Area �J Pit or Grout Inspection by Date Final Inspection by — Additional Comments: ❑ 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 r FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. NFO CASH 4 EH 1124 IREV.r e 5) /'i `1 - ✓✓�� EH