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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. 11362 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Z �" t Fad City Sized PM � 4 Owner's Name r Lo h �� Address S1 1 0 3 LJ ' 1 A--% Phone Contractor �L Address License No. Phone 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI 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_ Wet] Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Flier Material (Below 501 �tf TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is "I ° Installation will serve: Residence— Commercial Other available within 200 feet.) Number of living units: ! Number of bedrooms j UJ Character of soil to a depth of 3 feet: 9'f U d A---, Water table depth SEPTIC TANK P_"fiype/Mfg Capacity-1-1-f!:.0 0 No. Compartments } PKG. TREATMENT PLT. ❑ / 1 Method of Disposal (� Distance to nearest: Well:1-I Foundation Zo _ Property Line LEACHING LINE ❑ No. 8 Length of lines Tota length/size �� FILTER BED r B1'Dissttar� nearest: We?..[._ _ IF undation�_ _ Property Line.11v ++! G] 2. C. SEEPAGE PITS I I Depth Size Number SUMPS L� Distance to nearest: Well Foundation Property Line c DISPOSAL PONDS ❑ I 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, and 1 rules and regulations of the San Joaquin Local Health Di§trict. 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 for all req 'ed inspections. Complete drawing on reverse side, Signed X .. Title: wilkDate: C'+LZ 0 S FOR EPARTMENT USE ONLY Application Accepted by _ Date a Area Pit or Grout Inspection by Date— Final Inspection b F .1, Date 10— Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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' INFO RECEIVED BY DATE PERMIT'NO. +.Eli 13-24(REV.s/is sl EH 14-26 a