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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 Ryles and Regulations of the San Joaquin Local Health District. Job Address y-1 h 1:11 9 City Lot Size 1 ,a- PM Owner's Name Address Sit 5 Q �,y-+•d— Phone 9 49-44% Rae- 4f,f- 1.124 Contractor Address License No. — 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 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION D $TRUCTION ❑ (No septic system permitted if public sewer is N£w '�da:11G '� •"t" available within 20D feet.) - Installation will serve: Residence_ Commercial_ Other Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK f r Type/Mfg Capacity—A-Ny L No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ''mob* Foundation to * Property Line ,•'S 4– LEACHING LINE CO"No. & Length of lines Total length/size--4t2 FILTER BED ❑ Distance to nearest: Well ion t- Foundation�k Property Line t� $ar SEEPAGE PITS �4a'�l �V Number �_1 �Depth 2'S r Size t �} SUMPS ❑ Distance to,nearest: Well .1=-f U Foundation -0'4_ PropeM Line 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." Contractors 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." Theapplicant must call for all required inspections. Complete drawing on reverse side. p _ Signed )I� < 5le— Title: �7Z'rs�`.�G� Date: n� �O�DEPARTMENT �n� USE ONLY Date Area O� Ap lication Accepted by ..��JJ � Pit r Grout Inspection by ry'a �� `ya�,e Date Final Inspection b ze6OE�Date . Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82Y-71OW ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY - DATE PERMITNO. NFO SEH 13-201PEV.vest S, 0 13'2_ CC'- "� Zb -14�5 EH 10.]6