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APPLICATION FOR PERMIT SAN JOAQUIN•LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y * .}4§ n y . (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- ,. I f i3 v"l r- � d V�/� * Y Cis r �G Lot Size v' , PM i Job Address y city I Owner's Name_ Address w+ Q u�r Phone �� Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NE ELL ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ; ❑'Eastern Surface Seal'Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50')- Depth 0')Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.l w Installation will serve: Residence Commercial_ Other S Number of living units:_L_ Number of bedroom.ps - Character of soil to a depth of 3 feet: C1 4 '' - Water table depthq.` 1i '" c SEPTIC TANK 1d Type/Mfg Capacity --L2'D No. Compartments i PKG. TREATMENT PLT. ❑ rye .,cy p Method-of Disposal [� Distance to nearest:' Well 120 __. tFoundationZo-- Property Line 1-4 LEACHING LINE Pd No.& Length of Iihes 0 - '"1 Total ength/size 360 � r FILTER BED ❑..Distance to nearest: Well `1725 Foundation Property Line SEEPAGE PITS ` ❑ Depth Size. '� .° N mber SUMPS LJ Distance to nearest: { Well ' r` Foundation Property Line f � DISPOSAL PONDS ❑ I hereby 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. . . . % ! ' ;' - q # 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,1I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for al require inspections. Complete drawing on reverse side.� Signed X i i!�/a.td ----� Title: �� S� r u Date: �J 'a. FOR DEPARTMENT USE ONLY/ Application Accepted by 11J- 4 f11L�_ ' _ Date Area ! Pit or Grout Inspection by ^; ` Date ` Final Inspection by Date,�� Additional Comments: r�R1� - I\ ❑ Stk 466-6781 ❑ Lodi 369-3011 ❑ Manteca 823-7104 ❑ Trac 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;9 Stk., CA 95201 IFEE NFO AMOUNT DUE' CK AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. F -+ EH 13-24 IREV.t i H 57 /("� C1 %?0 EH 14-28