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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` City 012 OLAI ur Lot Size PM PM Owner's Name - I / 20, Address Phone Con1racI412.lF.d> t a2- f Address Y0. !> ",X 761 g�License No 1 J W_')�, Phon �J DOS— OS 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 J — C1 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ..11 ❑ Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout 1f l I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depthfiller Material (Below 50') l TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 EPAIR ADDITION tAl DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence Commercial_ Other f Number of living units: _L_ NumberoLf/f_edro8ms Character of soil to a depth of 3 feet: 17. 'uGee. Water table depth / t� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal fy Distance to nearest: Well Foundation Property Line fT� r LEACHING LINE No. & Length of lines — d Total length/size X FILTER BED 0 Distance to nearest: Well _ Foundation Property Line k'S r � u SEEPAGE PITS Wr/Depth C25 Size /�..��/� +3 Number i SUMPS Ll Distance to nearest: Well/0 Foundation/Q Property Line ti G 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." The applicant 1`iiicall for `allll.. ue id inspections. Complete drawing on rev lige. Signed X L -E ` Title: ' Date.' . �J ,J FOR JEpARTIMENT USE ONLY _ Application Accepted by r•i v a r e_ "1- Date —✓7 Area If Pit or Grout Inspection by : X r�/r/t-<% Dat 5 /Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. NFO AMOUNT DUE CASH SEM 124181V INF v- EH 14-28