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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Rules and Regulations of the San Joaquin Local Health District. t-�a ToLoc) ` I Job Address P�fl City ` Lot Size � ±PM Owner's Name Q �F�,��i� Address i7w`�►a�� phone Contractor�_7M Addressv� �+,�Zt�� License No.L��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 \ F1 Public F1 Other Cl 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_ v Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial X Other Number of living units: Numbe�f bedrooms Character of soil to a depth of 3 feet: Water table depth ' .Q SEPTIC TANK X Type/Mfg Capacity PCJ00)[-holl j4o. Compartments PKG. TREATMENT PLT. ❑ I I "* Method of Disposal Distance to nearest: Well Foundation iProperty Line LEACHING LINE No. & Length of lines Z (i 1C,O I!� f Total length/size �CLs-1 X 13 FILTER BED ❑ Distance to nearest: Welln�r fit+ t Foundation Property Line SEEPAGE PITS I I Depth Size _ Number \ r SUMPS Ll Distance to nearest: Well Foundation Property Line X 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 ust call for all requir inspections. Complete drawing on reverse side. may, Signed X Title: �-�TI "A,TdJZ_ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date a `� Area �Q Pit or Grout Inspection by Date Final Inspection byZY"Cla'�, Date Additional Comments:;4�a _ iekA4EA 1W / ✓ / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l,V ak �-$,Lk5+1-tl uK r4v Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. B,gxZ009, Stk., CA 95201 ekes Lie t. s >v c)leck �e�ct.otia� ��v. bc, �d�,5ht«vve FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. INFO CASH 11t7 Dl6P�-3 � a-a3ov a EH 13-24(REV.1/x5) o - o- C EH I4-2B 111