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i APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is.heteby 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. ,\ Job Address rjLA�� 'v= Qr �• City Lot Size L-7 ��o PM T Owner's Namethnu AA Address one t �S r t .Q /_-f Contract AddressQ.O. -u� �W 1 License No.19S DAD Phone.Rf-, 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 ( •_ v 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 f"1 Public E_l Other Cl Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done F1 Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION € REPAIRIADDITION I I DESTRUCTION l I Wo septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence' Commercial_ Other rg, Number of living units: Number of� � rooms Character of soil to a depth of 3 feet: z' Water table depth 111,®0 SEPTIC TANK PIR`�Type/Mfg Capacity No. CompartmentsIQ PKG. TREATMENT PLT. ❑ _/�. Method of Disposal ) Distance to nearest: Well 0 Foundation 1._0 Property tine S } txa LEACHING LINEL� -"�y No. & Length of lines � 6y Total length/size 1120 FILTER BED ❑ Distance to nearest''/i Well—KW—r- Foundation_ !b; Property Line -1 -- SEEPAGE PITS ls�- Depth o?S- , Size 33 Number IS. SUMPS ❑ Distance to nearest:;/Mell.--.100! Foundation © Property Line S DISROSAL PONDS ❑ I hereby certify that-{/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[he 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 shalt 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 mcall'for all Or d inspections. Complete drawing on reversers' e. Q Signed X Title: / Date: U { FOR DEPARTMENT USE ONLY Application Accepted by Date 1_1 Area f Pit or Grout Inspection by Data Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7184 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH . EH 13-24 IREV.i/H sl EH 14.28