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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.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. p Job Address / s .ACS S7�/h► rCCity iy/,4jyiG � Lot Size PM �y r Owner's Name "s Address �YD 61 .&S%!iV �Y /� Phone Contractor A, Address W:12( 14'y /477-<i4 License No�'S6_7M 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 Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is C� '/ available within 200 feet.) Installation will serve: Residence v Commercial_ Other V� Number of living units: _L— Number of bedrooms Character of soil to a depth of 3 feet: �'�, -DV ;41( Water table depth SEPTIC TANK ❑ Type/Mfg r ki Capacity /otter'V No. Compartments PKG. TREATMENT PLT. ❑ �r F� Method of Disposal Distance to nearest: Well 6 Foundation�_ Property Lined V LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation lOGProperty Line SEEPAGE PITS ❑ Depth Size Number 3 ' SUMPS ❑ Distance to nearest: Well. . Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and l 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 ofthe 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 Califomia."Contractors 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 must call for all r uired i :pec:ction Complete drawing on reverse side. It Signed X_ Ttle: L Date: FOR DEPARTMENT USE ONLY C Application Accepted by Date �d 7 O Area 13 s Pit or Grout Inspection by Date Final Inspection by Date �G Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-M 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 CK RECEIVED BY DATE PERMIT NO. INFO CASH .EH'13 Wa 3 • H 28 IREV.1/H5) \ EH 1428 i