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APPLICATION FOR PERMIT J R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 + I 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 sewge or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. L Job Address P 6, -06-0 Y citys�& Lot Size d e�d PM I Owner's Name�� l �+� Address Phoned 1? Contractor's Name SY&- kicense Nor-.�S__V_73 Y� Phone ezi "P 96 Q TYPE OF WELL/PUMP: NEW WELL ❑r WEL&'REPLACEMENT.❑ DESTRUCTION ❑ PUMP INSTALLATION 21 SYSTEM REPAIR ❑` OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK E SEVkR LINES DISPOSAL FLD. PROP. LINE FOUNDATION F / ,eAGRICULTURE WELL — OTHER WELL PITS/SUMPS INTENDED USE- t TYPE OF WELL rPR_OBLEWAREA—CONSTRUCTION SPECIFICATIONS M ❑Industrial "� ❑ Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravei Pack. ❑ Tracy M„ Type"of Casing i Specifications I ❑ Public ❑ Other ❑ Delta Deptlhof.;Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump t H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth' -,..Filler-Material-(Belo` ') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is ,t. / available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units:—Number-of=bedrooms f Character of soil to a depth of 3 feet:�� 4-,09 Y Water table depths 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE` No. & Length of lines . -7 0 i L.. ti Total'length/size e 4 FILTER BED ❑ Distance to nearest: Well i Foundation Property Line I k SEEPAGE PITS XoeDepth '$'r Size Vgf Number SUMPS ❑ Distance to nearest: Well af0 Foundation � Property Line _s DISPOSAL PONDS ❑ I I hereby certify that I have-prepared-this-applioation=end-that-the-work-will-be-done-in-accordant-eii it#t=Sara-Joaquin-county-ordinances-state laws, and rules and regulations of the San Joaquin Local Health District. I j 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 Iaws:of,Caliifornia." 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 call for all required inspections. omple_to drawing on reverse ide. f Signed X Title: [yam Date: ' FOR PEP TMENT USE ONLY Application Accepted by Date -"Ti Area a �p s`aFinal Ins Pit or Grout inspection by I to � Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9=1 FEE r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`N0. C : . ► � z�r r EH 13-24(REV. EH 1426