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J APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 and/or install the work herein described. This application is t 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 i Local Health District. - Job Address 57/q ,!�— g('44& City Lot Size PM Owner's Name } e, Address i 1 t 4 _ Phone Ou Contractor ddress C. License No.-� Phone Tc7� 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 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public f] Other ❑ Delta Depth of Grout Seal Type of Grout _ f i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done [IType of Pump _<�_ —H.P. State Work D° Well Destruction ❑ Well Diameter Seali g Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION L) DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence_ Commercial J__4 Otlier r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I,-V{ Water table depth I SEPTIC TANK ❑ Type/Mfgf Capacity No. Compartments J PKG. TREATMENT PLT. ❑ l � � Method of Disposal I Distance to nearest: W le I+'- Foundation Property Line i t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well` Foundation Property Line 0 0 I SEEPAGE PITS 13 Depth SizeNumber SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS E3 ', i F I hereby certify that I have prepared this application and that the ork will be done in accordance with San Joequih`6unt/ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. P °1( r Home owner or licensed agent's signature certifies the following: i I certify that in the performance of the worar which this permit is issued, I shall not i employ any person in such manner as to become subject to work q an'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 t ' ermit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif rnia." The applicant us call for u inspections. Complete dra Ing (1.1,J!,;ide,Signed X Tle. Date: //�% ® FO gEPARTMENT USE ONLY f Applicatio Accepted by �s� Da e / Area kr r Pit or Grout Inspection b Vl Pe y 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 r INFO AMOUNT '.D/,UE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. a.EH 1324(REV.t i x sl s-oo [ek!� EH 14-26 `/ F 1' � t i