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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. Job Address �T,G� J " "� ty '�-'� Lot Size'•'✓e`n" PM ` Owner's Name Address �� Phone �. aM1� �13-32�_ Contractor Address License No. Phone G: �� ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 �X ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t. M Public ❑ Other Ll Delta Depth of Grout Seal Type of'.Grout_ r I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - v Repair Work Done ❑ Type of Pump H.P. State Work Done _ ` Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence commercial_ Other Number of living units: Number of bedroorns� Character of soil to a de th of NZ 3 feet: /4 �� -� Water[able depth MID ` SEPTIC TANK Type/Mfg "e- C644r ex i/ Capacity_. No. Compartments 1- 1 PKG. TREATMENT PLT. ❑ r Method of Disgosal Distance to nearest: Well V Foundation w '7- Property Lined LEACHING LINE bid-No. & Length of lines Tctal length/size FILTER BED ❑ Distance to nearest: Well&-o �'t- Foundation roX Property Line 1 �. SEEPAGE PITS �f4' I Depth S Size Nu ber -� SUMPS ❑ : Distance to nearest: Well/_Od_�_ Foundation Z10z'r'' Property Line DISPOSAL PONDS ❑ I hereby certify that I havaprepared this application and that the work will be done in accordar a 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 performarlce 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." The applicant"Ast II for equired 'ffspections. Complete drawing on reverse side. 'y�7 Signed X r- Title: Date: FOR DEPARTMENT USE ONLY { Application Accepted by �- -- Tli_� Area - I��/ r Pit or Grout Inspection by Data Final Inspection by tom° Data 7�1�� Additional Comments: - �J,' - y '�`/`•' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CISH RECEIVED BY DATE PERMIT NO. INFO /')'y ` � EH 1824 IREV.1/xsl 9c EH it-M