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APPLICATION FOR PERMIT SAN JOAQUIN LOCAHEALTH DISTRICT L 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 fora 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 ��/ / l cityLot Size PM Owner's Name —,��/ f�' s' U �/ Address Phone Contractor's Name /!�i dE License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT' DESTRUCTION ❑ PUMP INSTALLATION,C SYSTEM REPAIR ❑ OTHER ❑ DISTANCE;TO NEAREST: SEPTIC TANK _/SD -" SEWER LINES' DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ClIndustrial ElOpen Bottom L1Manteca Dia. of Well Excavation Dia. of Well Casing G Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other - ❑ Delta Depth of Grout Seal �� ` Type ofd rout r I t ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump .r,s H.P. ��? State Work one Well Destruction ❑ Well:,.Diameter (rte Sealing Material (top 501 Depth 02.)r3' Filler Material {Below 501 F+J TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION El DESTRUCTION 13 (No septic system permitted if public sewer is �'--� available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 4 Character of soil to a depth of 3 feet:'""`J. E` - Water table depth SEPTIC TANK ❑ Type/Mfg --Y Capacity No: Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WeII `Foundation Property Line F � 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line . 7 � SEEPAGE PITS ❑ Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ " 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 JoaquinvLocal 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 ch r�ilanner 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.perfor nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californi ." The applicantco m li� r all uired i ons. Complete drawing on reverse"de. Signed i. ' nl .�- Title: i/ Date: FOR DEPARTMENT USE ONLY `� .=oar ®.. w..+ �. . ..q„•. ..� Application Accepted by q Date Area v _ 1 2- 1 Pk o rout I pection by Datel Final Inspection by Date fW� .lG Additional Comments: rr - Ol 171Stk 46fr6781 ❑ Lodi 369-3621 F1Manteca 623-7104 ❑ Tracy 835 �y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. INFO CASH + EH 13-241REV.101831 EH 14-26