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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�egulations of the San Joaquin Local Health District. Job Address _Z/-Z 10 .//�!f/�il/� if',/�_ City Lot SizePM Owner's Name /i1le _r/f.0/X1r, Address Phone -� 6 0/sl Contractor's Name 252,04 /f/2f !!S- ./t✓,S-License No. Phone X606__"?46 07 i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. 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 ❑ Domestic/Private ❑ Grpvel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ 04A6, ❑ 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 y� Well Destruction ❑ Well Diameter - Sealing Material (top 50') X Depth Filler Material (Below 50') 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 1 Number of living unite: L`� Number of bedrooms Character of soil to a depth of 3 feet: —Y4f,!L/J >✓ 40/7/1 Water table depth i n / SEPTIC TANK 2,—Type/Mfg ��/r'/c'/.C'/-f Capacity 1260 No. Compartments ;7— PKG. PKG. TREATMENT PLT. ❑ Method of Disposal L 1r �✓/T � ' Distance to nearest: Well_,52) Foundation 1_V Property Line "A LEACHING LINE No. 9 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well z5-0 Foundation �/Ar Property Lina SEEPAGE PITS © Depth Lr' Size .3, �/ Number SUMPS ❑ Distance to nearest: Well , 06 Foundation .3 0 Property Line DISPOSAL PONDS ❑ 1 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 persons subject to workman's compensa- tion laws of California." ,ape The applica t call for all required in ctiona. omplete drawing on revers'72e Signed X_7Z �C-�' Title: Date: !� FOR DEPARTMENT USE ONLY AAppplication Accepted by (�✓ Date Area Pito Grout Inspection by Final Inspection by Date d- J - Additional Comments: ❑ Stk 486-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7100 ❑ Tracy 836-63M Applicant- Return all copies to: Environmental Health Permit/Servloes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIYYJO. EH 13 24 10/831 V o P 7Z EH 1428 D