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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.543 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / ems Job Address v ? � �a Citys Lot Sizez (C7 e Pr Owner's Name-7, ) &a Address A�hn-,e Phone --- ii i r , - _ ' �— Phone Contractor's Name � yLk � TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C 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 C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificatlons u 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. I State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 50') .� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION i] DESTRUCTION C (No septic system permitted If public sewer is �+ available within 200 feet.) Installation will serve: Residence Commercial_ Other _Nurrzber of living units: Number o drocros 3 >� Character of soil to a depth of 3 feet: J!, Water table depth SEPTIC TANK ❑ Type/Mfg ____ Capacity No. Compartments PKG. TREATMENT PLT, :3 ' ' Method of Disposal I Distance to nearest_ -Well Foundation' Property Line 1 Y � {LEACHING LINE -~7Vo.l& Length of lines ' _ i Total lengthl�slz- 1 'FILTER BED �L Distance to nearest: 'Well ,/ 00 Foundation Property Line SEEPAGE PITS ❑ 'Depth "'f'^f Size Number SUMPS_ ❑ Distance to nearest: IWOI Foundation Property Line DISPOSAL PONDS ❑ L 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 perfomlance 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-contacting signature certifies the following:"I c fy that in the pe rmanoe of the work for which this permit is issued,i shall employ persons.su blect to workman's compensa- tion f California." The applican call for all aqui ]na ons. p e drawing o arse side. j Signe Tide: Date: ' t FOR DEPARTMENT USE ONLY _ Application Accepted by Data — J w Area • Date-- f". — -Pit -Date- y- — Additional Comments: "I '/ -" --t ClStk 466-6781 C3Lodi ElManteca 823-7104 C3Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haza]ton Ave., P.O. Box 2009, Stk., CA 95201� FEE AMOUNT DUE AMOUNT REMITTED R 'f'N RECEIVED BY DATE PERMIO. INFO +f +EH 1326 iREv.10/e31 EH 1426 �-�