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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. 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. 307-5—�-" Job Address r -- -- rn�/-� �/ /`�FS d�/.-� fcity �1 (.1Lot Size PM 34 Owner's Name 1 - W. r1C HH? E Address 2r J 2-1 J ' UC� Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ;K 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 PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications vJ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout G ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dom r n Well Destruction ❑ Well Diameter Sealing Material (top 50') V Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-%G Commercial_ Other Number of living units: Number of bedrooms R h (+ Character of soil to a depth of 3 fee[: Water table depth V SEPTIC TANK ;K, Type/Mfg Capacity ISO U No. Compartments Z PKG. TREATMENT PLT.❑ 1 1 Method of Disposal Distance to nearest: WellOI 01 0 -F-f Foundations Property Line '5 :': LEACHING LINE No. 8 Length of lines Total length/size Yd FILTER BED ❑ Distance to nearest: Well JW Foundation 1&4 f Property Line SEEPAGE PITS . Depth ---,o t 3 Z ^ (Number SUMPS ❑ Distance to nearest: Well t-4n II,L Foundation Property Line�f DISPOSAL PONDS ❑ 1 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 compens i- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed x I 1 \ �71 Q�1 f�1_. Title: O LA. M 4)-t- Date:tc• 3 lJ kOR DEPARTMENT USE ONLY �7 Application Accepted by Date /` 3/--�y Area prt dr Grout Inspection by� _ Data Final Inspection byDatg/ Additional Comments: Stk 466-6781Lodi 3�-3621 ❑ Manteca 8237104 ❑ Tracy 83543M Micant- Return all copy to: Environmental Health Permit/Services IBM E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. �I �_o� �l JAL t ✓� VL'0