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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. 7 Job Address 3 a! W3 16nG ;f I rs-L Q city 512101013 Lot Size PM r. Owner's Name i 001 0"Q XA, Address �-� 4'S Lana tPGZ- Phone Contractor 4.1, IC!' Address License No. ' Phone TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT ❑ DESTRUCTION ❑' '- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROF, LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITSI'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 l� ❑ Public O Other ❑ Delta Depth of Grout Seal Type of Grout �! ❑ Irrigation __4pprox. Depth ❑ Eastern Surface Seat Installed by W Repair Work Done ❑ Type of Pump R-1( State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Belo 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ (No septic systeM permitted iCpublic sewer is UA/ / available within 200 feet.) Installation will serve: Residence J� Commercial_ Other Number of living units: A_ Number of bedrooms t� Ib Character of soil to a depth of 3 feet: Uq&dAA Water table depth SEPTIC TANK ❑ Type/Mfg -� Capacity LI.60 No. Compartments r PKG. TREATMENT PLT. ❑ ^.�' Method of Disposal Distance to nearest: well Foundation 11' 4 Pro party Line LEACHING LINE -,- EF No.8 Length of lines lengthisize q/ FILTER BED ❑ Disp�a to nearest: Well_l rn, Foundation 1 �� Property Line SEEPAGE PITS 34K Depth '2E' Size �3 Number 7i SUMPS ❑ Distance to nearest: Well IJL�i� LFoundation Property Line DISPOSAL PONDS ❑ •,7 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: "1 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."Contractors hiring or sub-contracting 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." t.. The applicant must call for all required inspections. Complete drawing on reverse side. Com/' Signed X / �[� Title: tkue Date: -O V FOR DEPARTMENT USE ONLY Application Accepted by Date - 7- Area Pit or Grout Inspection Date Final Inspection b Lunw Y Date Additional Comments: ❑ Stk 466-6781 , ❑ Lodi 369-3621 ❑ Manteca 873-7106 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER NO. i EN 1324(REV.1/n 5) EH W28 QO