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I f APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ~ Telephotie (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 City 4'9 Lot Size V6/;'- PM e Owner's Name C,tt! _._ Address '?,9-AL4.— Phone Contractor Address 11 License No, g� 3 , Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. IN LE FOUNDATION AGRICULTURE WELL OTHER WELL PPROP.ROP. LME INTENDED USE TYP,E.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial [D Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingi Specifications M Public FI Other f 1 Delta Depth of Grout Seal Irrigation Type I f of Grout --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump . v State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') `--- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAlR/ADDITION 1 1 DESTRUCTION I 1 (No septic system permitted if public sewer is Installation will serve: Residence L�Commercial available within 200 feet.) Other i Number of livingl'units: Number f bed ms Character of soil to a depth of 3 feet: 4L SEPTIC TANK I Water table depth ie-Type/Mfg �� ' Capacity_� No. Compartments r PKG. TREATMENT;PLT. ❑ f Method of Disposal 1 Distance to nearest: WeEI�— Foundation_�Q Property Line ,0 I � LEACHING LINE CII�1rla. & Length of lines Q d Total length/size FILTER BED I ❑ Distance to nearest: Well_440 IrFoundation_a5" — Property Line 1AX ' I SEEPAGE PITS l'I Depth Size ✓.-. i Number SUMPS L] Distance to nearest: Well r' r�Foundation DISPOSAL PONDS Property Line 11 �`�'+� I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ,� y I Home owner or licensed agent's signature certifies the following: "I certif�that in the performance of the work for which this permit is issued, I steal!not employ y parson�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 em to tion laws of California. " p Y persons subject to workman's compThe appiica6t must call for all require ins ctions. Complete drawing an reverse side. r r �Signed�X� ) �C:.if] �s I Title: LGjl�r Date: . I FOR DEPARTs MEIVTI USE�ONLYr_q , Application Accepted by L- {- Date G Area Pit or Grout Inspe tion by Date ,.._3 Finally Inspect by p g [� U Additional CommeLs: Tf 1. Date ❑ Stk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return lallAcopies to: Environmental Health Permit/S rv'icte�s x1601 E.//Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE f 0 INFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVER BY PATE PERMIT'NO. + EEH 14-26 H 1324(REV.1/95) C4