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APPLICATION FOR PERMIT !! SAN JOAQUIN LOCAL HEALTH DISTRICT 7601 E. HAZE I 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/of install theworkherein 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. } rwfJ ((f Job Address __ � L1/\(� cc)urt Pm)CE,(- Lot Size PM Owner's Name C , bE15(1QJ 5��dress �� J Phone VF Contractor I Address License No. V, 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 Q)J ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public f_7 Other hl Delta Depth of Grout Seal Type of Grout---. 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Bone U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth x Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION i 1 DESTRUCTION I I (No septic system permitted if public sewer� is available within 200 feet.) Installation will serve- Re d C_Immercial Other Number of livingunits: Number of bedro,o�msW - Character of soil to a depth of 3 feet: sl r _P>6 Water table depth SEPTIC TANK N--<Ypa/Mfg' et& -^� - Capacity`_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _' Distance to nearest: Well 1,0or Foundation 1/D Property Line,- r LEACHING LINE . Y o. & Lengthyof lines 3 - VIs Total length/size'f FILTER BED ❑� Distance to nearest: Well Foundation PropertyLine SEEPAGE PITS fL3�apth J Sire.. Number t SUMPS Cl Distance to nearest: Well _.__-Foundation ' Property Line DISPOSAL PONDS ❑ I hereby certify that! have prepared this application an_d 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. 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 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 California. � The applicant call for I re ired i pec i ns mplete.drawing ro reverse s' e. Signed Title: �.._ Date: FOR DEPARTMENT USE ONLY 'Application Accepted by .Date Tea Pit or Grout Inspection by x Date _ ,Final Inspection by Date r 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 INFO AMOUNT DUE AMOUNT REMITTED GK 49 ASH RECEIVED BY DATE PERMIT'NO. ♦ EH1324(REV.1/m51 EH 14-2e - `�. F