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APPLICATION FOR PERMIT I SAM JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES Z YEAR FROM DATE ISSUED r (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 H 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. tt Job Address 7271 S. Nelson i.1.. Stockton 5 acres , PM City_ ' Lot Size _ I Owner's Name Jean Smith _ Address 7271 5• Nelson Phone 4�5=$693 _ Contactor _GARNER -1 ONSTRIlCTIDN Address 74nn Wren R,4 ._(lakrlala License No.A-R 44186R Phone8-4.Z OF WELLVPUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE h FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN7ENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Incustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications f'} Puclic n Other ..I n Delta Deprh of Grout Seal _ Type of Grout ( n I I Irngar ca —Approx. Depth l } Eastern Surlace Sedl installed by r Repan Work Done 0 Type of Pump H.P, ' Stale Work Done Well Destruction ❑ Well Diameter. Sealing Material Itop 50'1 Depth Filler Material (Below 50') TYPE'OF SEPTIC WORK: NEW INSTAbL4TION XX REPAIR/ADDITION A DESTRUCTION 1 1 (No septic system permitted if public sewer is I available within 200 feet.) Installation wilt serve: Residence A2 I Commercial— Other Q Number of living units: 1 Number of bedrooms . 2 Character of soil to a depth of 3 feet:hard_pan Water table depth 100 ft. d. SEPTIC TANK ID Type/Mfg I mo_^ _ Capacity. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest,. Well- Foundation Property Line LEACHING LINE )0 No. & Length of lines 1 X 40lin ft - Total length/size altm- FILTER BED M Distance to nearest: Well - 96+Foundation 25' Property Line 7201 r SEEPAGE PITS ITXI Depth 25''.* — Size 36". die• Number 2 SUMPS 0 Distance to nearest: Well1©61_____ Foundation 35 r_ Property Line 220.r DISPOSAL PONDS ❑ 1 I W I hereoy 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 subcontracting 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." I The applican ust It fqr U r fired inspections. Complete drawing on reverse side. Signed X- !� .�� .Title: Owner/Garner Construction _ Date:FOR DEPARTMENT USE ONLY 111 ' r— f I Application Accepted by T:J Date �- Area If Pit or Grout Inspection by _ Date�� Final Inspection by slate� I` Additional Comments: 114" U2 ❑ Stk 4666781 0 Lodi 369.31321 0 YAanteca 823-1104 ❑ Tracy 935-630 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelt6n Ave., P.O. Box 2089, Slit., CA 95201 - INFO AMOUNT DUE j AMOUNT REMITTED CASH RECEIVED 9Y DATE I PERMET'NO. EHSpEV.r/n51 / /c dV ..4 l uiU� C�� Ff`-//r•-ci �a EH IC24t4.ae L f