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APPLICATION FOR PERMIT V SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON 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. I { on Job Address �✓ yo �� 6 � City Lot Size PM Owner's Name �ya�,�iC�l�ts�13�lk Address _11;� - Phone Contractor -S-E'.�i/� AddressLicense No. Phone �I _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL i OTHER WELL - PRS/SUMPS LINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indusulal ❑Open Bottom Q Manteca Dia. of Well Excavation Dia.of Well Casing -. ❑ Domestic/Private Cl Gravel Pack ❑Tracy Type of Casing Specifications 1� r'1 Public 0 Other Ll Delta Depth of Grout Seal Type of Grout L I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction O Well Diameter Searing Material (top 501 CY Depth Filler Material I8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.)Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms • 4�`^'� 7 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK f7 Type/Mfg C� Capacity bo No. Compartments PKG. TREATMENT PLT.0 �— !\ ,� ethod of Disposal Distance to nearest: Well Foundation Prope .Line �. LEACHING LINE 0 No. &L 11I6 ength of lin s 1,� gtal length/size AA FILTER BED Distance to nearest: Well r1 oundation f Property Line J-4� ` SEEPAGE PITS 11 Depth Size Number V SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0, 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 pernt is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractols hiring or suGcontracting signature certifies the following:"1 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 apRitea4it'must call for all required inspections. Complete drawing on reverse side. {A Q Signed X \�I1//1 Title: 0?-� Date: �fl '� v T USE ONLY r Application Accepted by Ake a _ Date ""� Area Pit or Grout Inspection by Date Final Inspection by I+"'1.� 'Date _ r Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO- IFFE RECEIVED EH 13-24(REV.lin sl 'V nV(l �l.!: t!� � dz) EH 1416