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i APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA �L Telephone 1209) 466-6781 v PERMIT EXPIRES 1Y EAR 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. t City Lot Size_� � PM Job Address �^ Owner's Name : )k n f) Address Phone Contractor �''� C Address 6201-4 r License No.�L�57�r Phone 93 € TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION rl # PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS kf El Industrial ❑ Open Bottom ❑ Manteca Dia. of WellExcavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"1 Public ❑ Other + L-i Delta Depth of Grout Seal Type of Grout---- I rout —I I Irrigation _..Approx. Depth 11 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADD1710N - DESTNUCTION M. septic system permitted if public sewer is J available within 200 feet.l Installation will serve: Residence, Commercial Other Number of living units: . Number of bedrooms — 7 Character of soil to a depth of 3 feet: cS*0 t2 /a Water table depth , SEPTIC TANK 94,' Type/Mfg Capacity l/06 _ No. Compartments PKG. TREATMENT PLT. ❑ � or / r Method of Diispnosak Distance to nearest: Well Foundation - /� Property Line LEACHING LINE Fr_ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r/ lr SEEPAGE PITS 14'Depth � Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l 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 mus a111 l for all req a in ctions. Complete drawing on reverse side. Signed X Title: Date: RDEPARTMENT USE ONLY Application Accepted by , R a-•-�^ Date �- 1`� Area --`l I Pit or Grout Inspection by Date Final Inspection b Date z z 6 o Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. INFO A y +.EH 13.241AEV.i/mt0 %, ,� �''2.7 b 90-17(b EH 14.26 V