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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781- PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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 �' W City V Lot Size Owner's Name ' / Address Phone" � Address } NS� J;?.'Ph'one Cantactor !a - - _TYPE OF WELL/PUMP: w NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I 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 j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L7 Domestic/Private - ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - hl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-- I rout I I irrigation Approx. Depth I 1 Eastern Surface Seal Installed by - + Repair Work Done• ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth. Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION JV REPAIR/ADDITION Ll DESTRUCTION l I (No septic system permitted if public sewer is Md available within 200 feetA Instaliation will serve: Residence _ Commercial X_ Other" Number of living units: Number fbofbedrgpms 1` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑" TypelMfg �� fi=r Capacity .C� No. Compartments PKG. TREATMENT PLT, Llrj I"�c�.S�. VL 3 e_,C> TYA-P Method of Disposal Distance to nearest:' Well foundation Property Line LEACHING LINE ❑ lNo. & Length of lines In ion P- Total length/size fi FILTER BED r � ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ¢l,l:-. Depth Size Number 31 , k SUMPS �, Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �� :' r'a�� kI hereby certify that I have prepared this application and that the work will be done in.accordanca with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. rHome 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: r, employ any pefson 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." r } The applicant must.caH for all req d pectin s. Complete drawing on reverse side. 4 Signed 'itle: _�_R AAA, e6 Date: + ' FOR DEPARTMENT USE ONLY `/ Application Accepted by Date v�an— Area `y � ' Pit or Grout Inspection Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Codi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO +� + EK 13-24(REV.I/N5) - 1� _ � 97-43-12.1 FFFI EH 14-M