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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELT 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address O6' k City Lot Size PM Owner's Name Address 7M ti, cj_oF t& i { r C 07( 7107 [ License No,.32 2(C Phone, 6J-_ 1e Contract Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-El _ _ry DESTRUCTION ❑ i 4 PUMP INSTALLATION ❑ E, ' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP. LINE '"T FOUNDATION "' AGRICULTURE WELL OTHER WELL PITS/SUMPS _ I i " INTENDED'USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing a ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [� FI Public ❑ Other 1771 Delta Depth of Grout Seat Type of Grout---,- l I 1 Irrigation —..Approx. Depth i I Eastern Surface Seal Installed by ` i Repair Work Done ❑ Type of Pump H.P. . State Work Done �} Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION IJ DESTRUCTION I I (No septic system permitted if public sewer is M available within 200 feet.) Installation will serve: Residence Commercial' Other Number of living units: Number of b Brooms r Character of soil to a depth of 3 feet: - - .8 Water table depth ) i SEPTIC TANK Er-Type/Mfg L� Capacity 4590 No. Compartments 1 PKG. TREATMENT PLY. ❑ s Method of Disposal Distance to nearest: Well �4 :...__._.- Foundation Property Line LEACHING LINE VK No. & Length of lines - Total length/._e X FILTER SED ❑ Distance to nearest: Well .M Foundation .Property Line S OF SEEPAGE PITS ! I Depth —�� _Size Rx /6 Number ` OF SUMPS EFI�Distance to nearest--�,.;.Well.'f�Foundations w Property.Line DISPOSAL PONDS- ❑ 1 "Yhereby 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!ifbllowing: "I certify that in the performance of the work for which this permit is issued, i shalt not employ any person,in such manner as to become.sittiject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I•cartify that in�thj6'Performance of the work.for which•this permit'is issued,`I-shail employ persons subject to workman's compensa. tion taws of California." The applicant m call for all rniM inspections. Complete drawing on raver a e. t Signed X J" Title: : z Date: �_a 0J IJ 7 i ' FOR EPARTMENT USE ONLY Application Accepted byi ' ' Date Area -IWo rout Inspectiort by bate " not Inspection by Date Ad'ditiona� 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 I r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. f INFO `'� CASH y f ; EH14-26IREV.t/1451 4 LO V1� 101 i-k—� E