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APPLICATION FOR PERMIT -.001 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 Rubs and Regulations of the San Joaquin Local Health District. _ '— Job Address ,(city �4�� Lot Size 7 4&-es PM (7-,9-e Owner's Name t/ !r-�r4old Address / V e0,e 7,r7 tlrC 147/' Phone 33`1. 77 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ I. 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications f'I Public ❑ Other El Delta Depth of Grout Seal Type of Grout 1 1 1r :ion _Approx. Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material (lop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION W DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_!L� Commercial_ Other (_ Number of living units: / Number of bedrooms -7 V l` Character of soil to a depth of 3 feet: Ss/�ci Isom Water table depth ,S Y'' SEPTIC TANK ❑ Type/Mfg L[an Gl'C ��.�trllof Capacity No. Compartments 2— PKG. TREATMENT PLT.❑ _ --4- Method of Disposal / f/Distance to nearest: Well CS Foundation /5 Property Line LEACHING LINE A No. 8 Length of lines — 01-7 0 Total length/size 2 yd ¢ ... FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size _ Number ` SUMPS 0, Distance to nearest We02)(II /ZU Foundation Property Line DISPOSAL PONDS O 2'C 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 reputations 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 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 applicamn�t!&pbst�caall for all required in action . Complete drawing on/mv�e�rsa side. Signed X /' a a• -Title: Date: I FOR DEPARTMENT USE ONLY Application Accepted by �/ j .e t'ey Area Da Pit or Grout Inspection by Date Final Inspection Data Additional Comments: '•/�Z'i'r ❑ Stk 9864781 O Lodi 3693821 O Manteca 823-7104 O 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 RECEIVED BV DATE PERMITNO. INFO IREV.r,ssr