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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. Job Address ..7� f7'L[/`y _L .._....- __ CitycC9�N Lot Size/,5Z Je 12 PM Owner's NameAddress Phone ~�� I Contractor's Name License No. �_PhonewQ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Y 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 CONSTRUCT_ ION.'SPECIFICATIONS ❑ Industrial ' l ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing °❑-Domestic/Pridate ❑ Gravel Pack -" S�l Tracy" Type of Casing Specifications j OV.Public, `y ti ❑.Other ❑-Delta _ Depth of,Grout Seal Type of Grout I11 Irrigation �4pprox. Depth F] Eastern_ Surface Seal Installed by Repair Work Done C1 Type of Pump. H.Pa {'- State Work`Done Well Destruction ❑ Well Diameter' Sealing Material (top 50'1'r Depth �{ Filler Material {geaw 50'1- '� �✓ TYPE OF SEPTIC WORK: NEW INSTALLATION❑. .'REPAIR/A'DDITION DESTRUCTION•E3 Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial j Other `Y Number of living units:__/_ Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1-1 Type/Mfg `' - Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ � Method of Disposal Distance to nearest:{t Well Foundation`7'z'. Property Line S1 LEACHING LINE ;X, No. & Length of lines Z'r'it649!' W W_ Total length/size 1 FILTER BED I] Distance to nearest: Well 1!!0tirS t Foundation -! r Property Line S23' SEEPAGE PITS Depth ods Size Number SUMPS ❑ Distance to nearest: Well Fo nudatibn }�7 Property Line DISPOSAL PONDS ❑ .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 I rules and regulations of the San Joaquin'Local Health District. n A F e r 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 hlr6g or sub-contracting signature certifies the folio ng: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to worRinan's compensa- tion laws of C -imia." The app acallfora quire in ctions. C mplete drawing o v se side. _' 1 011 Signed Title: Date: FOR DEPARTMENT USE ONLY A Application Accepted by CL.,, Date �.�j �' Area Pit or Grout Inspection by Date �� Final Inspection byDate Ad tional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C1 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 i AMOUNT'REMITTED N_A s`.-CK# CRECEIVED�BY _DATE PERMIT'NO. .,INFO— EH INFO—EH 13-24(REV.10183) EH 1426