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ly APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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.. /� 1 Job Address 11 q,3Q g w!�"I 12- City 01(Atk-- Lot Size c:2 AG PM Owner's Name 0eAzVl�_ I< +)� Address (7 3 �` Jt`�GlX3-►� �— Phone Contractor 4 r�_ Address JZF!� , roCay License No. 0 3Phone 3 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 v 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public n Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation .Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l DESTRUCTION I I (No septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence Y/ Commercial_ Other © t, Number of living units: —t— Number edrooms� 7 �^ Character of soil to a depth of 3 feet: �n (� -L,f>.9M Water table depth SEPTIC TANK f� T z Type/Mfg COD — �Q'.r` Capacity 14,QLD No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal 061 Distance to nearest: Well—LsZ— Foundation Property Line LEACHING LINE LYNo. & Length of lines Q1 Total length/size FILTER BED HI Distance to nearest: Well Foundation 3S , Property Line 'P6 SEEPAGE PITS 10"'Depth a5 Size 3(o ,,,Number .Z SUMPS Ll Distance to nearest: Well_J3�I Foundation _ Property Line /6-1 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 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 must call t5f all r9quired inspections. Complete drawing on reverse side. / �+ Signed X //! Title: DIs��L'� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date /V-Area 0 '*��Pit or Grout Inspection by Date I /IgFinal Inspection by AW4Q— Date Additional Comments: ❑ Stk 466-6781 XLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all c pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IEEEO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT' N/O. . EH 13-24IREV.1ix5) 0( d EH 14-26