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APPLICATION FOR PERMIT _ AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA _ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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�egulations of the San Joaquin Local Health District. Job Address ,/./-z J 0 s/A/D`&AI r dca City 1G/)/ Lot Size-fOACf�FS -t-- PM Owner's Name Address f f`'. Phone 0/ y Contractor's Name f-'f: f.'/1f_`/ 1C}'L'11 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT -❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r 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 r ❑ Industrial IT Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grfvel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Othgrr�. ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _q g Approx. Depth ❑ Eastern Surface Seal Installed by .� Repair Work Done ❑ Type of Pump H.P. State Work Done y, Well Destruction ElWell Diameter Sealing Material (top 50'1 LJ c Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Or REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic,system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units:�,. Number of bedrooms Character of soil to a depth of 3 feet: -I f3.d!/1 4 G,/7/7 Water table depth J� SEPTIC TANK B"-Type/Mfg oe2,e2 .-'/f ff Capacity--Z 2610 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation ID Property Line X LEACHING LINE No. & Length of lines / '— y Total length/size— FILTER ength/size FILTER BED ❑ Distance to nearest: Well ;YD Foundation ` 6 Property Line /r ,' A SEEPAGE PITS Depth 7,-f-' Size .7-9 `/ Number ` SUMPS ❑ Distance to nearest: Well 6 1_ Foundation $ f/ Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 persons subject to workman's compenw- tion laws of California." The applica t call for all /rey�ui aid In cticns. o�mplots drawing on reverse Signed XTitle: - Date: FOR DEPARTMENT USE ONLY ` Application Accepted by Date < Area o/ i V Grout Inspection by Final Inspection by "''�� Date d' S Additional Comments: ❑ Stk 4ee-8781 ❑ Lodi 369.3821 ❑ Manteca 823-7104 ❑ Tracy 835.63815 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH;3.0 IREV.10/811 p _EH 1430