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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—t ON 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 CL/��/N�' City �'� Lot Size I"&G PM T 7 � Owner's Name L ,(2 AI t2 � 272 J �� Vl 159/9 Address 2 4,14iV,6 Phone Contracts -A Address �V License Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 ❑ 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 ' ^n Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is Vn' available within 200 feet.) !� Installation will serve: Residence Commercial_ Other Number of living units:__fL_ Number of bedrooms a— _ Character of,soil to a depth of 3 feet: 5'.Aw�)/ *r✓I Water table depth SEPTIC TANK- E7 Type/Mfg d"!_+ Capacity_/0&V__ No. Compartments , PKG. TREATMENT PLT. ❑ F.r% fT Method of Disposal Distance to nearest Well '�� Foundation 4'24re4 Property Line LEACHING LINE ❑ No. & Length of lines Total length/91�e FILTER BED ❑ Distance to nearest: Well Foundation ro r Pty Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Fgyndation 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 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." i The applicant must call for aJllj�Quired 'nspections. Complete drawing on reverse side. ' Signed X � Title: 6z -�,o.L/ Date: FOR RR DDEPAR ENT USE ONLY Application Accepted by ,/G- Date Pit or Grout Inspection by // Date Final Inspection by DateV Additional Comments: e s'r 641L 0 Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-71Q4 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By ..-y DATE PERMIT NO. EH 1426