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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 { f (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 f �/ p�/�� } s Job Address _ /V r/OA zS City Lot Size L0 PM Owner's Name Address Phone woo Contractor Addres_ -z,3 l�LF License Nd 730 =Phene� TYPE OF WELL/PUMP: NEW WELT. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1kr' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _.__-_ SEWER LINES DISPOSAL FLi7 ( -._ PROP. LINE I FOUNDATION AGRICULTURE WELD OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom EJ Manteca Dia. of Well Excavation LI Dia. of Well Casing Domestic/Private %'Gravel Pack -- ❑ Tracy Type of Casing �C_ Specifications +« f`I Public ❑ Other ❑ Delta Depth of Grout Seal S-4) Type of Grout I I Irrigation f 34-..Approx. DeptI I Eastern Surface Seal Installed by C 4- -a Repair Work Done ❑ Type of Pump /.S H.P. State Work Done _ o Well Destruction ❑ Well Diameter Sealing Material {top Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.� REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is ._ Installation will serve: Residence_ Commercial_ Other - available within 200 feet.) kk Number of living units: Number of bedrooms �l Character of soil to a depth of 3 feet: 1 Water table depth s SEPTIC TANK r ❑ Type/Mfg Capacity No"Coi i_p tment'�'`^- PKG. TREATMENT PLT. L1Distance of Disposal Proper Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �. FILTER BED 171 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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 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 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 call for all required inspections. Complete drawing on reverse side. � l Signed [T Title: K-- Date: — zg-x _ 4 FOR DEPARTMENT USE ONLY . { Application Accepted by Date" L ' Area Pit or rou' 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 FEE AMOUNT DUE AMOUNT REMITTED INFO I CASH RECEIVED BY DATE PERMIT'NO. �EH 13-24 IREV.118 51 / � r EH 14-26 117111"'/(�,�.. Zdgz-n p