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�o '• 35 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH. DISTRICT 1601 E. HAZE T 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/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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. kob Address % CC9 or,/e! ity �/C�19 ! - Cot Size /5` j PM y�0wner's Name Address ne Contractor d �� Address License No. 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 i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I.1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation .-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ {1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below-50')- 94- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION JK QESTRIJCTJO e'tic system permitted if public sewer is _ _~ available Installation will serve: Residence Commercial_ Other y _Number of livingunits: Number f o N t� Character of soil to a depth of 3 feet: Water table:depth SEPTIC TANK �I Type/Mfg Capacity__V2.� , No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ _Distance to clearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number e SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 Diltrict. 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 laws of California." The applicant must c tar all required inspection rpp to drawing on reverse side. ,("igned X Tit e: Date: R DEPARTMENT USE ONLY ` Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by F Date fo e Additional Comments: d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 104 acy 83 -6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE MOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ASH +.EH13-24 IREV.1 i n 51 t©� --Zrj/ qa 20 - 6 6 EH 14-28 fi[ KJ