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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED w (Complete in Triplicate) Application is her 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 1` Local Health District. Job Address City Lot Size PM m - Owner's Name ��^"7 �'��2�".�.� S- Address - -� — _ Phone Contractor i 2 � fl_664l_ Address I Fbt MT6-A License Na. J ,j�Phone PTYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT [IDESTRUCTION (71'i- PUMP„INSTALLATION.❑ { SYSTEM REPAIR ❑ '. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES\ _ f�DISPOSAL FLD. PROP. LINE F FOUNDATION AGRICULTURE WEL^L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL' F PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom% ❑ Manteca t" Dia..•of Well Excavation i Dia. of Well Casing ❑ Domestic/Private C1 Gravel Pack �1 ❑ Tracy) Type Of,Easing } t Specifications 09 ❑ Public ❑ Other - ❑ Delta Depth of Grout Seal # Type of,Grout (� ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Typo of Pump H.P. State Work!Done, Well Destruction ❑ Wel Diameter Sealing Material (top 50) Depth ~' Filler Material(Below 50'); i TYPE OF SEPTIC WORK: NEW INSTALLATIONr REPAIR/ADDITION�J DESTRUCTION 1-1 {No septic system permitted if public sewer is I ? available within 200 feet.) Installation-will.serve: rResidence LZ,Commercial�- --.,-Other--- Number �- -- Other- -- � - Number of living units: Number of bedrooms . Character of_soil to a depth of 3 feet: Q Do 3 'Water table depth SEPTIC TANK1 , ' ❑ Type/Mfg Capacity ff- PNo. Compartments PKG. TREATMENT PLT. ❑ ,; _ - 7— 'Method of Disposal G Distance to nearest: Well 4=6jndation & Property Line �� --- T r LEACHING LINE 1x No. & Length`6f lines '"�- '� u'' 0.. .s Total length/size Z, rad FILTER BED ❑ Distance to nearest: Well Foundation Property LineFiT-- i SEEPAGE PITS ❑ Depth Size y X'S ' C� "=' �� Nffinberc� SUMPS ° Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will,be'done in accordance with San Joaquin countyordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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 cartify,that in the performance of the work for which this peimif is issued;I shall employ persons subject to workman's compensa- tion laws of California." The applicant mustcallfo�Vl quire inspections. Complete drawing on reverse side. Signed X -f� z Title: ' ' r Dater F - i f F R DEPARTMENT USE ONLY l NC . .Application Accepted by Date Area a7 _ Pit or Grout Inspection by 'Date Final Inspection by Date. 4 lAdditionai Comments: ' ❑ Stk 466-6781 ❑ Lodi" 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant- Return all copies to! Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 --�- FEE^ ^"AMOUNT DUE={ 4 OUN.T REINITTEDw"` CASH r� RECEIVED BY' -.,_ .—DATE" •'PERMIT'NO_W ^^ -�y INFO +EH 13-24 SREV.17 e 57 S�_V EH 1426 : F