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1-ft-0 APPLICATION FOR PERMIT ""01 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cornplete 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. TMs 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. ` s n Job Address -..-36 y7 0 , S0 e (— � �f�Ciitty 44,4 �2Q_ Lot Size C�C— PM Owner's Name //��/� ESJ ®' Address j�Q *2?" Phone n Contractor mak/ re Address �LGL/� License No. �OS 7.� Phone 6 a Jj 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 FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ 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 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 110T DESTRUCTION I I (No septic system permitted if public sewer is available within 2D0 feet.) - I" Installation will serve: Residence ✓ Commercial_ Other LP Number of living units: —I— Number ofooms Character of soil to a depth of 3 feet: n "— Water table depth f 1 SEPTIC TANK L3- Type/Mfg _:Cnses Z5 yte— Capacity - f2 No. Compartments J PKG. TREATMENT PLT.❑ f r Method of�Diis-ppos�al Distance to nearest: Well�D Foundationj/O _ Property Line J sV LEACHING LINE L�No. & Length of lines r3 1 Vo Total length/size d FILTER BED ElDistance to nearest: Well `?Q I Foundation 3 Q/ Property Line 20 b SEEPAGE PITS I✓l7epth .2 5 r Size Number 3 SUMPS L1 Distance to nearest: Well /e2ms�n Foundation f 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." The applicant /mist/call for all�reJgd.. dC/ spections. Complete drawing on^reverse side. Signed Xo&oZ: ��c/ Title: Date: FOR DEPARTMENT USE ONLY �1 Application Accepted by ,}— Date I o�� Area 7,� or Grout Inspection by/ Date / —�a F�►.al Inspection by r— _'—DataJ�L'"3'7 Additional Comments: ❑ Sik 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`20000009, Stk., CA 95201 yam+ FEE INFOAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. CASH . EH M24(REV.I i x 51 s�91O/Z �Gf EH IC25 I .—�