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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r. 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. Lot Size_? GtC1"�S� PM 4. Q Owner's Name O� �� Leel . Address / �¢ 75--7 lf��- �� Phone -3 Contractor Address fl License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER .Fl 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 1x Depth of Grout Seal _ Type of Grout }-. I I Irrigation —.Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State.Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i&r DESTRUCTION Vit'(NO septic system permitted if public sewer is $j available within 200 feet.) �a Installation will serve: Residence Commercial-_ Other (/ Number of living units: _._-L--.-_ Number of bedrooms 3 .' Character of soil to a depth.of 3 feet: Soli O(Z 4~71 Water table depth SEPTIC TANK ❑ Type/Mfg e_ Gi-e_ - Capacity No. Compartments Z r r PKG. TREATMENT PLT- ❑ =f, _fes_ Method of Disposal Distance to nearest: Well `� Foundation 15Property Line LEACHING LINE Yui No. & Length of lines 0 "1 )-7 G Totat length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line tj I SEEPAGE PITS, ('I Depth Size _ Number� J + SUMPS D4.- Distance to nearest: We1127t l LU Foundation 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 r rules and regulations of the San Joaquin Local Health District. � 'I # 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 riot 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 foliowing: "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 st c_all for all required in ti - complete drawing on reverse side, Signed X a le—Title., Date: FOR DEPARTMENT USE ONLY Application Accepted by j ✓ - Date { / Area / ! F= Pit or Grout Inspection by l Date Final Inspection-}� �- Date Additional Comments; -/Vo ❑ Stk 466-6781 ❑ Lodi -339621— ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 FEEJi INFO: AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. +.EH 13-24(REV.1/x sl ^•� C� EH 14.26