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n, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTt 1601 E. HAZE T ON AVE., STOCKTON, CA VL/ 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address / �! �1` ai_9_7� CityR Lot Size PM Owner's Name � Address Phone -33-3 � � �✓� Contractor o/ +�� Address pe—W K. : License No Phonu+ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('l Public n Other 17 Delta Depth of Grout Seal Type of Grout--- I rout _I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 j Depth Filler Material lBelow 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I RFPAIR/ADDITION Ll DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) . Installation will serve: Res i encs X Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK � Type/Mfg L Capacity No. Compartments 21 PKG. TREATMENT PLT. ❑ �J /1 Method of Disposal +°x0� "T" Distance to nearest: Well Foundation 0 Property.Line ) LEACHING LINE No. & Length of lines [/ Total length/size FILTER BED Distance to nearest: Well ��P Foundation Property Line- - I SEEPAGE PITS t I Depth Size Number 0 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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. Home owner or licensed agent's signature certifies the following: "t 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 st call fo all requir d inspe rxs. omplete drawing on reverse si e. Signed X Title: date: "" n, FOR EPARTMENT USE ONLY t1 Application Accepted by �R' tlsfaNA Y_ Data Pit or Grout Inspection by Date Final Inspection by Date 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 INFO AMOUNT RUE MOUNT REMITTED CASH RECEIVED BY DATE PERMITN70ttt yyy +"Ek3-241REV.1/N51 EH 14-26 V t;J }�-