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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. ,� Job AddressA � � City� Lot Sy iz�1y � PM I f� f a Owner's Name ,�i }!!?z- Address 7 4 ✓ Phone 67Or1 ' ' P ��7 z 9226 Phone 6rN/0 Conlract tial Addressg. � License iVo., 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 ❑ Grave! Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other n Delta Depth of Grout Seal Type of Grout _ I Irrigation _--Approx. Depth I ] Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. -State Work Done_ Well Destruction ❑ Well Diameter Sealing Material ftop 50'1 Depth r' (Below 50') (� TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR?ADDIT19 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of b rooms yd G. 3 Character of sail to a depth of 3 feet: l Water table depth SEPTIC TANK Type/Mfg Capacity aW No. Compartments PKG. TREATMENT PLT. ❑ Method'of Dirosal ` Distance to nearest: Well— -- Foundation—/d �— Property Line__ Ofr LEACHING LINE No. & Length of lines Total length/size X z- FILTER BED ❑ Distance to nearest: Well !!;-6 Foundation Property Line SEEPAGE PITS I)K Depth Size , Number SUMPS 0 Distance to nearest: Well 4010 Foundation��.- Property Line � 1j DISPOSAL PONDS ❑ "� t 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, anv rules and regulations of the San Joaquin Local Health Di$t7rict. 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." 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 t call fOrrwired inspections. Complete drawing on reverse si e. 91 Signed X Title: 1 / _WizDate: 1aL./ :1G 0 FOR DEPARTMENT USE ONLY Application Accepted by Date !1 Area GP't or Grout Inspection by Date Final Inspection by Date y Additional Comments; 7r~tJ ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY /DATE PERMIT NO. +.EH 13-241REV.1in5r _)0 EH 14-28