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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. 14 ` 7 / Job Address 4/ (2 City c-/;--t�P Lot Size 1• GSL Ac , PM Owner's Name ,/ /4.110 l.C')77Ff�• �uC Address --14/ Z (J �z u/ �� Phone Z r Z/ /C,--e c - Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION a SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTEND-r!) USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial C Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing C ❑ 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 `Nell Destruction = Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION C (No septic system permitted if public sewer is y available within 200 feet.) Installation will serve: Residence L Commercial X� Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: ��n-v u — c/d i/ a Water table depth / (r• SEPTIC TANK ❑ Type/Mfg Cap�pi No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to nearest: Well �ZC r Foundation zO 4 T Property Line 37 r LEACHING LINE �' No. & Length of lines 2 — Total length/size r FILTER BED ❑ Distance to nearest: Well 20 Foundation � Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 Califomia." Contractors hiring or sub-contracting signature certifies the followin c rtify 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 Califo ia." The applicant st II fo all r ed irfpe ti s. Co tete drawing on v side, Signe X Title: Date: F R DEPARTMENT USE ONLY Q �j Application Accepted Date/ ` � Lj- ll Area Pit or Grout Inspection Date Final Inspection by Date 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 FI RECEIVED BY DATE PERMIT NO. INFO Q EH 13-24 iREV.i,A 5 1 u 1 Ct c� cfc EH ta28 _� ^ -y...� j