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APPLICATION FOR PERMIT 'I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED k (Complete in Triplicate) r 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. �j d5� 7/33 /1� �•rr-e-rt: _ r 30 c-c�t fJ PM'�Of� Job Address _ I City Lot Size Owner's Name J Address ` 6334 Phone r Contract ' �' Address 8 Z. License No. ? Phone '�' �� i TYPE OF WELL/PUMP: NEW WELL ❑, WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION 11SYST,EMAREFPIR.C] OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER`LINES/Z - _DISPOSAL FLO. PROP. LINE '� 1.' tS _ FOUNDATION AGRICULTURE WELL "�0T.I1ER�_WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM,AREA-fCONSTRUCTION SPECIFICATIONS `'� � �• 1 ❑ Industrial ❑ Open Bottom ❑ Manteca/ F !Dia. of Well Excavation Dia. of Well Casing . ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ,. Type of Casing Specifications 171 Public ❑ Other C] Delta Depth of Grout Seal Type of Grout — I I Irrigation _"Approx. Depth I I Eastern .,'--.Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Weli Destruction CI WeII Diar Teter " Sealing Material Itop 501 Depth w Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION € I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feetid t. I Installation will serve: Residence Commercial'_ Other Number of living units: —/— Number of rooms 3 ' t Character of soil to a depth of 3 feet: Water table depth - 42 SEPTIC TANK Lz}-�_ - Type/Mfg �'� Capacity od. No. Compartments � PKG,TREATMENT PLT" Ll �y r f .Method of Disposal ^ Distance to nearest: Well �� Foundation 10 Property Line Y LEACHING LINE LK-No. & Length of lines 0 Total length/size & -R FILTER r r � r f FILTER BED ❑ Distance to nearest: Well - Foundation Property Line .- SEEPAGE PITS Pyr Depth CVS Size ?� Number d SUMPS ❑ Distance to nearest: Well�Z Q Foundation�M Property Line DISPOSAL PONDS El-- /11 -_ I hereby certify that I have prepared this application arid that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules.and regulations of the San Joaquin LocaLHealth bistrict" Home owner or licensed agent's signature certifies fhe 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 laws of California." I • "� The applica must call r I re ired inspections. Complete drawing on reverse IctN Signed Title:' V`r Date: FOR DEPARTMENT,USE ONLY Application Accepted by J� Date /J< Area��71 L q Pit r Grout Inspection by Date_Final Inspection by Date ��%� i 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ' r EFI 13-24 TREY.r H 55 �70 EH 14-28